The DIR Model
The DIR model attempts to facilitate understanding
of children and their family by identifying, systematizing and integrating the
essential functional developmental capacities. These include the child’s 1)
functional–emotional developmental level; 2) the child’s individual differences
in sensory reactivity, processing and motor planning; and 3) the child’s
relationships and interac-tions with caregivers, family members and others.
Functional–Emotional
Developmental Level
The child’s functional–emotional developmental
level examines how children integrate all their capacities (motor, cognitive,
lan-guage, spatial, sensory) to carry out emotionally meaningful goals. The
support for these functional–emotional developmental levels is reviewed
elsewhere (Greenspan, 1979, 1989, 1992, 1997). These capacities include the
ability to:
· Attend to
multisensory affective experience and, at the same time, organize a calm,
regulated state (e.g., looking at, listen-ing to, and following movement of a
caregiver).
· Engage
with and evidence affective preference and pleasure for a caregiver or
caregivers (e.g., joyful smiles and affection with a stable caregiver).
· Initiate
and respond to two-way presymbolic gestural commu-nication (e.g.,
back-and-forth use of smiles and sounds).
· Organize
chains of two-way social problem-solving commu-nications (opening and closing
many circles of communication in a row), maintain communication across space,
integrate affective polarities, and synthesize an emerging prerepresen-tational
organization of self and other (e.g., taking dad by the hand to reach a toy on
the shelf).
· Create
and functionally use ideas as a basis for creative or im-aginative thinking,
giving meaning to symbols (e.g., pretend play, using words to meet needs,
“Juice!”).
· Build
bridges between ideas as a basis for logic, reality testing, thinking and judgment
(e.g., engage in debates, opinion-ori-ented conversations and/or elaborate,
planned pretend dramas).
These biologically-based individual differences are
the result of genetic, prenatal perinatal and maturational variations and/or
deficits and can be characterized in at least four ways:
1) Sensory
modulation, including hypo- and hyperreactivity in each sensory modality,
including touch, sound, smell, vision and movement in space;
2) Sensory
processing in each sensory modality, including audi-tory processing and
language and visual–spatial processing. Processing includes the capacity to
register, decode, and comprehend sequences and abstract patterns);
3) Sensory–affective
processing in each modality (e.g., the abil-ity to process and react to affect,
including the capacity to connect “intent” or affect to motor planning and
sequencing, language and symbols). This processing capacity may be espe-cially
relevant for ASD (Greenspan and Wieder, 1997, 1998).
4) Motor
planning and sequencing, including the capacity to se-quence actions, behaviors
and symbols, including symbols in the form of thoughts, words, visual images
and spatial concepts.
Relationship and affective interaction patterns
include develop-mentally appropriate, or inappropriate, interactive
relationships with caregiver, parent and family patterns. Interaction patterns
between the child and caregivers and family members bring the child’s biology
into the larger developmental progression and can contribute to the negotiation
of the child’s functional develop-mental capacities. Developmentally
appropriate interactions mo-bilize the child’s intentions and affects and
enable the child to broaden his/her range of experience at each level of
development and move from one functional developmental level to the next. In
contrast, interactions that do not deal with the child’s functional
developmental level or individual differences can undermine progress. For
example, a caregiver who is aloof may not be able to engage an infant who is
underreactive and self-absorbed.
The DIR model examines the developmental capacities
of the children in the context of their unique biologically-based processing
profile and their family relationships and interactive patterns. As a
functional approach, it uses the complex interac-tions between biology and
experience to understand behavior. Im-plementation of an appropriate assessment
of all the relevant func-tional areas requires a number of sessions with the
child and family. These sessions must begin with discussions and observations.
The assessment process which is described in detail
else-where (ZERO TO THREE, 1994; Greenspan and Wieder, 1997) includes: 1) two
or more clinical observations, of 45 minutes each, of child–caregiver and/or
clinician–child interactions; 2) devel-opmental history and review of current
functioning; 3) review of family and caregiver functioning; 4) review of
current programs and patterns of interaction; 5) consultation with speech
patholo-gists, occupational and physical therapists, educators and mental
health colleagues, including the use of structured tests on an as-needed,
rather than routine basis; and 6) biomedical evaluation.
The assessment then leads to an individualized
functional profile which captures each child’s unique developmental features
and serves as a basis for creating individually-tailored intervention programs
(i.e., tailoring the program to the child rather than fit-ting the child to a
general program). The profile describes the child’s functional developmental
capacities and contributing biological processing differences and environmental
interactive patterns, including the different interaction patterns available to
the child at home, at school, with peers, and in other settings. The profile
should include all areas of challenge, not simply the ones that are more
obviously associated with symptoms of one or another syndrome or disease. For
example, the preschooler’s lack of ability to symbolize a broad range of
emotional interests and themes in either pretend play or talk is just as
important, if not more important, than that same preschooler’s tendency to be
perseverative or self-stimulatory. In fact, clinically we have often seen that
as the child’s range of symbolic expression broadens, perseverative and
self-stimulatory tendencies decrease.
The functional approach to creating a profile
enables the clinician to consider each functional challenge separately, explore
different explanations for it, and resist the temptation to assume that
difficulties are necessarily tied together as part of a syndrome (unless all
alternative explanations have been ruled out). For ex-ample, hand flapping is
often related to motor problems and is seen when children with a variety of
motor problems become excited or overloaded. Many conditions, including
cerebral palsy, autism, hypotonia and dyspraxia involve motor problems and, at
times, hand flapping. Yet this symptom is often assumed to be uniquely a part
of the autistic spectrum. Similarly, sensory over- or under-reactivity is
present in many disorders and developmental varia-tions. Yet it is also often
assumed to be a unique part of autism. The functional approach does not detract
from understanding existing syndromes. In fact, over time, it may clarify what
symp-toms are unique to particular syndromes, lead to new classifica-tions, and
further tease out biological and functional patterns.
Constructing the child’s profile of functional
capacities through appropriate clinical assessments enables the clinician to
tailor the intervention program to the child’s and family’s unique features,
rather than have the child fit the program, based on some broad, but nonspecific,
diagnostic criteria.
As the DIR model suggests, any intervention or
treatment program should be based on as complex an understanding of the child’s
and family’s circumstances as is possible to achieve. It is the responsibility
of any psychiatrist who is charged with doing a full diagnostic work-up and
planning an appropriate intervention program to take into account all the relevant areas of a child’s
functioning, using state-of-the-art knowledge in each area. These areas include
the following
·
Presenting symptoms and behaviors
·
Developmental history: past and current affective,
language, cognitive, motor, sensory, family and interactive functioning
·
Family functioning and cultural and community
patterns
·
Parents as individuals
·
Caregiver–infant (child) relationship and
interactive patterns
·
The infant’s constitutional–maturational
characteristics
·
Affective, language, cognitive, motor and sensory
patterns
·
The family’s psychosocial and medical history, the
history of the pregnancy and delivery, and current environmental condi-tions
and stressors
The process of gaining an understanding of how each
area of functioning is developing for an infant or toddler usually requires a
number of sessions. A few questions to the parents or caregiver about each area
may be appropriate for screening but not for a full evaluation. A full
evaluation usually requires a minimum of three to five sessions of 45 minutes
or more each. A complete evalua-tion will usually involve taking the history;
direct observation of functioning (i.e., of family and parental dynamics;
caregiver–in-fant relationship and interaction patterns; the infant’s
constitu-tional–maturational characteristics; and language, cognitive and
affective patterns); and hands-on interaction assessment of the infant,
including assessment of sensory reactivity and process-ing, motor tone and
planning, language, cognition and affective expression. Standardized
developmental assessments, if needed, should always build on the clinical
process described. They may be indicated when they are the most effective way
to answer spe-cific questions and when the child is sufficiently interactive
and can respond to the requirements of the test.
The result of such a comprehensive evaluation
should lead to preliminary notions about the following:
· The
nature of the infant’s or child’s difficulties as well as her or his strengths;
the level of the child’s overall adaptive capacity; and functioning in the
major areas of development, including social–emotional relationships and
cognitive, language, sensory and motor abilities in comparison to age-expected
developmental patterns.
· The
relative contribution of the different areas assessed (e.g., family
relationships, interactive patterns, constitutional– maturational patterns, stress)
to the child’s difficulties and competencies.
· A
comprehensive treatment or preventive intervention plan to deal with 1 and 2.
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