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Monday, December 28, 2009

Getting to Co-Regulation

Once your child is feeling comfortable, and is no longer resisting the time you spend just being together, you are ready to take the next step. 

The first step in building co-regulation is to establish a simple pattern.  I will list some common starting points here.  When choosing an initial pattern to work with, keep in mind your child's individual strengths and challenges.  Do not choose a pattern that will be too challenging for your child.  For example, if your child has motor planning issues, don't try to toss a ball back and forth.  You may have to try several patterns prior to finding one or two that work well.  This is okay - you are learning what works along with your child. 

Some common starting patterns include:

Back and Forth - Tug of War:   With this pattern, you and your child will engage in a tug-of-war, where you take turns pulling back and forth.  You might use a pool noodle, or a jump rope, or even just hold hands and rock back and forth.  The most important thing is for your child to realize that s/he is taking an action that is in response to an action you've taken, so start out very slowly.  I would generally start this by holding firmly, but gently, to the child's hands, then slowly pulling back, so I am rocking back a bit, and the child is rocking forward (both of you in a seated position).  Pause, and wait for the child to pull you back.  This is critical - the child must understand that he is taking an action in response to your action.  This is why you must resist the impulse to push back yourself - the child must do it.  Once you feel the child pulling you back, pause, and pull back again.  Continue this pattern until it is comfortable and well-established. Once the pattern is established, add a small variation, like pulling a little to the side, instead of straight back.  If your child is comfortable with the variation, continue.  If not, go back to the original pattern.

Back and Forth - Rolling a Ball: This version of back and forth works best with a child who will remain with you without physical contact.  It is exactly what it sounds like - you will take turns rolling a ball back and forth.  Resist the urge to "tell" your child to roll the ball, instead show him what to do.  If necessary, start with a version of push and pull as described above, but with the ball in your hands, and gradually move towards rolling the ball.  Once the initial pattern is established, add variations, like changing speed, or bouncing the ball.  Again, if your child becomes upset at the variations, return to the original pattern.

Giver-Receiver:  A simple way to establish a giver-receiver pattern is to place two laundry baskets nearby.  The one closest to you will be filled with towels or small, soft items that are not distracting to your child.  Slowly, hand one item to your child, and show him that you want him to place it in the other basket.  Continue the pattern until it is well-established.  Once the pattern is established, add variations, like adjusting the speed, or tossing the items to your child. 

These are a few examples of ways we introduce co-regulation.  Remember, it's never about the activity - the activity is nothing but a framework in which to introduce the concept of co-regulation to your child.  It's not about tossing a ball, or putting towels in a basket - it's about your child learning that s/he can respond to your actions in a fluid manner, without needed to resort to withdrawing or controlling the interaction.  We keep these interactions simple and repetitive so your child can see the underlying pattern - the part that is the "same", before we start to add differences (variations).  These patterns are the backbone of co-regulation, so never rush them. 

Monday, December 21, 2009

What is Co-Regulation?

Co-regulation is the "dance" of social interaction. It is one of the earliest means of communication developed in infancy.

Co-regulation is unpredictable, but not too unpredictable. It rests on the premise of "My actions are influenced by, but not controlled by, your actions, and likewise, your actions are influenced by, but not controlled by, my actions."

For example, think about having a conversation. What you say is going to be influenced by, but not controlled by what your partner says. Your partner's responses, likewise, will be influenced by what you say, but you do not control their responses. It is unpredictable, in that you do not know exactly what your partner will say, but it is not so unpredictable that you are confused. Your partner's responses are influenced by your responses, so your partner will likely respond with something that is on-topic and makes sense.

This "dance" develops in early infancy through a series of daily interactions with parents and caregivers. Think about a simple game of peek-a-boo. It might start with mommy hiding her face behind her hands and peeking out. If baby responds with a smile, or a giggle, mommy might do it again. As the game goes on, mommy might add more variations to the game, hiding her face behind a blanket, for example. Baby might also respond in different ways, laughing at one variation, studying another, and eventually, turning away and signaling that the game is over. The game is unpredictable, but not so unpredictable that it becomes confusing for either mom or baby.

Children with autism have difficulty with co-regulation. They have difficulty seeing the underlying patterns that help us to make sense of the interaction, so to them, co-regulation is completely unpredictable. Many individuals on the spectrum respond to co-regulatory interactions by either a)withdrawing, either into themselves, or physically leaving the situation, or b)trying to control the interaction - talking incessantly about a preferred topic or insisting that their partner follow a script.

So, how to we help our children with this? The first step is to spend time just "being" with your child. You are not trying to get any specific response from your child, you are simply "hanging out" with no agenda. This can be tricky at first, as many children will respond by either trying to withdraw or controlling the interaction. This is where we often recommend sitting side by side on a couch or a porch swing. Make sure there are no distractions around (tv is off, no special interest toys or video games, etc.).

The rules are as follows: You cannot leave. This is a strategy we've often referred to as "I won't make you do anything, but I'm not letting go." Hold your child's hand, if necessary, and gently but firmly insist that you are sitting together for the duration. Start with small intervals (5 minutes, or even less, the first day, build up from there). The object is to let the child know that s/he must stay with you, but that you are not going to try to "get" them to do anything in particular. This is a sore spot for many children on the spectrum, especially those who have been through behavioral programs and are used to therapists who expect them to perform specific tasks. This is not about performance, it is about learning how to interact. It may take several days, but once your child knows that s/he is not going to be pressured to perform, their resistance generally lessens.

Rule #2, do not allow the child to control the interaction. This is where some children will attempt to take control by talking about an obsessive topic of interest, or insisting that you engage in a script with them. If your child is talking about an obsessive interest, tell them that we are not talking about that right now. If necessary, wear headphones to give your child a visual cue that you will not participate in the interaction. Don't worry if s/he keeps talking anyway, just stay with them, but do not engage in conversation about the obsessive topic. Use the same strategies with a child who tries to get you to participate in a script. Stay calm, do not participate, and hold on, even if your child is upset. This is where it is important to set a limit, until your child makes the discovery that s/he is not being asked to perform. Once that occurs, the resistance generally fades, but it can take time, so be patient.

Setting the stage for co-regulation is one of the more difficult aspects of getting started, but it is critical to future success. This part can be difficult for parents, because you are often feeling like you are not really "doing" anything. Trust me, you are setting the stage so you and your child can "do" great things later. Getting through your child's initial resistance is difficult, so make sure you have support and downtime of your own, because staying calm is critical. Hang in there, take your time, and know that your patience and faith will pay off.

In my next post, I will discuss taking this from "hanging out" into co-regulation

Monday, December 14, 2009

I'm Back, With Apologies

Hello everyone! I'd like to apologize for my absence over the past months - it has been a busy, eventful time for my family. My son, who has a history of seizures, had a setback this summer, and we have been working hard to help him through. The good news is that he is doing much better now, and I would love to share a bit with you.

Alex had a follow-up EEG last spring. It showed no seizure activity, so we were advised to take him off his meds. At first he was doing fine, but we noticed several things over the summer that were alarming. His sleeping patterns were interrupted. He started to complain of frequent headaches. Occasionally, he would eat until he vomited. Most disturbing, he regressed in his RDI program - his ability to read facial expressions regressed, he became more inflexible, and his stimming behaviors and high-pitched noises increased.

My RDI Consultant (yes, I have an RDI Consultant, even though I am also trained in the program. She has the distance necessary to help me see our progress and setbacks as they are, not as I would like them to be, and she is wonderful) felt that he might still be suffering from seizures, though they were likely so deep into his brain that a basic EEG would not pick them up. She recommended a doctor in Deerfield, Illinois who could do a test called a brain SPECT scan, which could pick up on activity deep inside the brain.

The SPECT showed seizure activity, as well as helping the doctor to pinpoint which parts of his brain are under-active and which are over-active. We started by putting him on depakote to treat the seizures. It took a few months to build him up to the proper dose, and during that time we noticed regression and progress in fits and starts. The general pattern was to see some regression right after we raised the dose (for example, he would get really obsessive over a toy, or have a hard time waiting to do something he really wanted to do). After a day or two, this would pass, and we saw big changes. He started reading my facial expressions again. He started imitating facial expressions.

We saw other incredible changes. He started spontaneously greeting his peers. He is showing curiosity and asking questions, like "What did you have for lunch today?" He is teasing his brother, which is annoying, but so normal. He follows me around like a toddler and wants to help me clean the kitchen or cook dinner. In many ways, his is like a preschooler. My background is in early childhood education, and he reminds me a great deal of the preschoolers I've worked with - seeking interaction, asking many questions, not always behaving appropriately, but learning with consistent redirection and guidance. He is finally at a place where I can guide him again.

We still have a long way to go. His doctor wants to work on stimulating his prefrontal cortex, so we will be starting neurofeedback next year.

I will continue to update you on how he is doing, and to get back to my posts on RDI. Again, I apologize for my absence, and I will do my best to post here regularly again.

Happy holidays to all!