DAISY’S STORY A STORY OUT OF THE BOX

1. DAISY’S STORYA STORY OUT OF THE BOX

2. Daisy’s story – imagine Challenging body Sensory system which can’t filter and differentiate Seeing the world in two dimension Difficulty to organize the output (ideas, motor, language)

3. Imagine… • She is different from other babies, “typical babies” people say • Slow in her development • Observant, but not responding • Independent, maybe too independent? • Not adjustable • Very sensitive • Has medical problems (in our case, vision)

4. Daisy’s story begins at… • September 2004 • First daughter for her parents • Vision impairments/ surgeries • Developmental delay • Early intervention 18 months - SLP/OT/PT/ABA/PRT • Special Education Pre-school & Parent Programs • Diagnosed with Cognitive Delay (2y + 11m) Autism (3y+ 4m) • Joined San Diego Cooperative Charter school at the age of 5- Full Inclusion in mainstream school • I met Daisy when she was 7

5. Meet Daisy’s team School: full inclusion SLP School consultant/team coordinator OT Professional collaboration based on DIR approach

6. D through a DIR lens The D – Social emotional development? The I – Individual unique profile? Sensory modulation? Sensory processing? Motor planning? The R – Supporting her self-regulation? Co-regulation? “just right” dance?

7. OT with a DIR point of view Activity Daily Life Regulation and Co-Regulation Survival mode “Flight, Fight or Freeze” – feeling safe Readiness for social interactions Readiness for academic environment Sensory life style

8. Daisy’s D = FEDL- 7 years

9. Daisy’s I = Individual Profile Social emotional Cognitive Anxiety Visual spatial Communication & Language Sensory-motor: Regulatory-Sensory Processing Postural challenges

10. Regulatory-Sensory Processing Capacities Over-responsive, fearful, anxious pattern • Over-responsiveness to any stimulus • Excessively cautious and afraid • Rigid and limited routine • Difficulty with transitions and changes • “fight or flight” response

11. Visio-Spatial Capacities Two-dimensional vision Excessively cautious about movement and space (stationary) Lack of body exploration Lack of environmental exploration Difficulty in gazing and making eye contact

12. From old reports: “She had congenital ptosis, infantile esotropia, and high level of hyperopia and has worn glasses since 4 months of age. She had eye muscle surgery to correct the strabismus in April 2005 and the ptosis was surgically corrected at December 2005”

13. Motor Capacities Postural and movement challenges • How is vision affecting her postural control? • Head control? • Gazing? • Trunk control? • Movement?

14. Language Capacities Poor shared attention Poor joint attention Poor reciprocity Poor affect cueing Poor articulation and oral praxis Lack of comprehension Using 1-2 words for initiating ideas

15. Anxiety Factors • Sensory modulation • Visual spatial processing • Language • Motor planning

16. When interacting with each other Using senses Rhythm Back and forward interactions Intimacy Recognize each other face expressions and non verbal communication

17. Co-regulation • "continuous unfolding of individual action that is susceptible to being continuously modified by the continuously changing actions of the partner“ • “As a simple example of co-regulation, a speaker may adjust their words or tone of voice based on their perceptions of a listener's facial expressions or body language - and this may occur on an ongoing basis” Alan Fogel, 1993

18. OT based on DIR approach Regulation and Co-regulation Parents are the key for successful process Dance Threshold Recovering/regrouping Pacing Giving her the time to respond Feeling safe/trust

19. Working on three DIR levels at the same time • Level 1 – Regulation – tent, body position, dad is the physical and emotional encore, predictability of the stimulation, arousal level • Level 2 – Engagement – emotional exchanges, reading her cues, giving her the time to signal • Level 3 – Back and forth interactions – giving her the time to respond, initiations, reciprocity

20. Challenges in therapy Progress is slow Inconsistency with regulation Daisy needs lots of support to be regulated and engaged in therapy Daisy is still very anxious in her daily life Movement is still an area of struggle

21. Self-reflection thinking Priorities – what should I focused on? Regulation? Opening circles of communication? Flow of Interaction? Predictability? Postural? Movement? Vision? Vision tracking?

22. Development of Visual/Spatial Capacities • 1. Body awareness and sense • 2. Location of body in space • 3. Relations of objects to self, other objects and people • 4. Conservation of space • 5. Visual logical reasoning • 6. Representational thought “Understanding the developmental sequence is important for setting appropriate expectations and knowing when to back down when filling existing gaps in the child’s development” Serena Wieder & Harry Wachs, 2012

23. Sharing attention around “Beauty Salon” • Regulation – letting others touch her, working on her body and skin modulation, body support • Engagement – motivation, meaningful activity Sharing attention around nail polish • Opening more circles – imitations, ideas • Starting to work on body awareness the first development stage of Visual/Spatial Capacities

24. What did we achieve? • Regulation – more variable interests, flexibility, calm mode, wealth of being, trust • Readiness – arousal, attention • Engagement – People and relationships are more meaningful then objects • More circles of communication, more intent, more ideas