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Chapter: Essentials of Psychiatry: Diagnostic Classification in Infancy and Early Childhood

The DIR Model - Diagnostic Classification in Infancy and Early Childhood

The DIR model attempts to facilitate understanding of children and their family by identifying, systematizing and integrating the essential functional developmental capacities.

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 Developmental Capacities


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).


Individual Differences in Sensory, Modulation, Processing and Motor Planning


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.


Relationships and Interactions


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 Functional Developmental Profile


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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