CCPR: Can you begin by telling us what is unique about the Profectum Foundation?
Dr. Wieder: At Profectum, relationships are the driving force of intervention. We embraced the DIR (Developmental, Individual Difference, and Relationship-based) Model I developed with the late Dr. Stanley Greenspan. DIR was revolutionary. It redefined functional emotional development through 6 processes related to shared attention, regulation, engagement, communication, social problem solving, and symbolic thinking integrated with individual differences in sensory and motor processing. It created a multidimensional model never before available to ASD. We also pioneered parent-mediated intervention (PMI), where parents learn to tailor interactions to their child to create joyful connections that promote developmental processes. Our interdisciplinary training integrates the knowledge of different therapies with educational, medical, and other sciences.

CCPR: How do you see a child with autism?
Dr. Wieder: When I think of a child with autism, I want to discover who he is—not just his diagnosis, but how he relates, feels, functions, and learns in the context of family, culture, environment, and education. I might discover he can use an iPhone to deliver his favorite songs, even before talking. We focus back to human communication but also see potential pathways, looking for strengths and challenges. Noted pediatrician Dr. Berry Brazelton demonstrated that newborn infants have unique capacities to respond to caregivers and the world around them. So do children with autism.

CCPR: So, you are saying that our approach to treating autism should never be a one-treatment-fits-all recipe?
Dr. Wieder: Autism has many variations. A one-size-fits-all approach will not address unique needs. A complex disorder requires a comprehensive dynamic relational approach that is flexible and modifiable depending on the child’s progress.

CCPR: How do individual differences impact clinical practice?
Dr. Wieder: Just think of any 2 children you know—perhaps your own children—and the impact is clear. Each child has unique passions, ways of taking in sensations, and ways of moving and learning as well as regulating and relating. For children on the autism spectrum, such differences have greater impact. A child may remember a thousand words and recite many scripts but may not be able to have a conversation or take your perspective. Motor difficulties may foreshadow minimally verbal adults. A child clinging to the schoolyard fence may have poor visual-spatial processing, motor control, and coordination. He may be worried about being bumped, or about sounds being too loud. The sensory-seeking child may be aggressive, with poor inhibition. The self-absorbed avoidant child may struggle with sensation and movement as well as anxiety, executive functions, and neurobiological challenges. We know how to intervene. For example, we can improve communication by increasing gestures and changing the pace and affective tone of our talking to convey meaning, or by changing the environment and making it quieter and less bright with more movement breaks.

CCPR: Can you tell us more about the kinds of factors we should look at?
Dr. Wieder: Think of development as dynamic lifelong processes interacting with each other. Start by looking for shared attention and regulation. Are the child and parent in synchrony, calm, and attentive? Are they engaged? At first, look for pleasure, but also look to see if the relationship safely supports anger or fear without disconnecting. How does the child manage anxiety, jealousy, competition, impulsivity, etc? How does the caregiver do the same? As development unfolds, look for problem solving, thinking, empathy, and theory of mind necessary for friendships and independence. Development has its own time table, and thinking in terms of lifetime processes tells us to keep working at every age.

CCPR: How do the child’s differences impact behavior?
Dr. Wieder: Behavior often means problems, but a given behavior may have a positive function. Perhaps the behavior is a “solution” and can help us understand the underlying problems. For example, a child who shuts down or gets disruptive may be overwhelmed by noise, not comprehend language, and need movement or more parent playtime. An anxious or sensory-seeking child may “jump from the frying pan into the fire” by acting impulsively or aggressively. Thinking about the meaning of behaviors multidimensionally leads to better solutions. NIMH’s Research Domain Criteria (RDoC) also examines dimensions rather than symptom lists (https://www.nimh.nih.gov/research-priorities/rdoc/index.shtml).

CCPR: How can child psychiatrists use ideas about individual differences, developmental tasks, and relationships to frame the intervention?
Dr. Wieder: Start with dynamic assessments and interventions. Observe the parent-child interaction and play, and join by coaching or getting down on the floor to play too. Notice what the child initiates, and how he does so intentionally. Or, is the child aimless and repetitive? Does dyspraxia, anxiety, attention, or ideation impede the creation of a story? Is he lost in fantasy? Perhaps he is moving all the time or changing topics? Does an attempted conversation turn into an “interview?” Does the child understand your intent? You will know if you’re engaged and what it feels like being with this child. Check your hunches about strengths, what is derailing progress, and what further assessments you need. You may not learn all you need to know at once, but subsequent meetings with family, teachers, and therapists will sort out intervention priorities.

CCPR: During the intervention, what are some of the other important things to look for with the child?
Dr. Wieder: Keep reevaluating the rate of progress, gains, or emerging challenges. Step back and see if the child has a greater sense of agency and intentionality; if she communicates spontaneously and demonstrates self-awareness. What do the child’s mind and body tell you? See what the child initiates and see how long of a continuous flow you get. If not clearly intentional, treat whatever she does as purposeful to get a back-and-forth and wait, as retrieval may take longer. Process rather than content is important here. Just as assessment is intervention, intervention is assessment.

CCPR: What do we do when a child is rigid in thinking or manner?
Dr. Wieder: Consider function again. Being rigid might mean predictability for some, so the same road must be taken, the same shirt worn, the same food eaten, the same sequence followed, etc. Rigidity also offers control to contain anxiety when change is not understood or useful and pleas go unheard. When power struggles ensue, we know who wins! Avoiding change and insisting on sameness paradoxically offers the child security and, though hardly adaptive, tries to avoid anxiety, stress, or anger—yet, too often, it results in dysregulation of child and parent. For such children, flexibility comes through the back door. Playing affords lots of flexibility and acquisition of “power” in symbolic ways. Your child can cheat, win, be the king, and even be the bad guy.

CCPR: So, what is some of the other value of play?
Dr. Wieder: In play a child learns to negotiate, makes deals, tries to outwit, works on anxiety, and begins to allow defenses to give way; the child can figure out the perspective of others while experiencing safety within the relationship. Symbolic thinking advances with affective cuing using gestures, tone of voice, and movement to convey meaning, anticipation, and excitement; it also opens the range of experience leading to discovery and flexibility. It is through affect that the child’s inner and outer worlds meet. Sometimes, however, it is not only the child who is rigid. Consider whether the child is locked into structured intervention, where only one answer is right, routines are overdone, and surprises are not welcome. Increasing choices, exploring new territory, and practicing skills—especially movement—also loosen the grips of rigidity. There have to be options and desire to take its place.

CCPR: How do we sort out what parents are experiencing, so we can better help the child?
Dr. Wieder: By being willing to ask about their feelings and experiences, as well as concerns. Every parent has hopes, dreams, disappointments, and worries. Parents have specific concerns that we need to know. As children grow older, most parents worry, “Who will love and care for my child when I am no longer there?” “Will my child have a meaningful life?” Also, discover parents’ joys. While we support being in the moment and capturing glimmers of potential during our sessions, we also explore thoughts about the future. Parents give us their vision, and our goal is to address hurdles, encourage competencies, and support their relationship. When we work with a child, we work with the family and use the reflective process to help them and ourselves.

CCPR: How might you contrast the various autism intervention styles, such as applied behavior analysis (ABA) versus developmental approaches with very young children?
Dr. Wieder: ABA therapists want children to learn and teach skills systematically using operant conditioning for compliance. ABA relies on taking data and most often uses discrete trials. But now some ABA models with young children are focusing on joint attention, interaction, giving more choices, and early symbolic play. Some include parents and blend interventions. With earlier intervention, sitting at tables and restricting movements, rewarding every drill is hardly developmentally appropriate. Today, developmental science is more relational. Neuroscientists find biomarkers and neural signatures for ASD before symptoms appear. Can we be preemptive? All of us know every infant needs parents and relationships. Given neuroplasticity, we have the opportunity to use relationships to shape social and emotional development and address the core deficits of autism. In DIR, rewards are intrinsic through joyful interactions and emotional thinking. To see this in action, please sign up at www.profectum.org for the free Parent Toolbox, a series of webcast videos that illustrate how to assess, play, and engage children with autism of all ages.

CCPR: Can you tell us more about some of the research that’s been done?
Dr. Wieder: We have 30 years of clinical-based evidence supporting DIR and can now cite RCT parent-mediated studies. The yearlong Play and Language for Autistic Youngsters (PLAY) Project Home Consultation study of 120 children, ages 2–6 years, found significant improvements in autism symptomology, caregiver/parent-child interaction, social interaction, and social-emotional development, as well as less parent stress and depression. No effects were found for language or IQ (Solomon R et al, J Dev Beh Pediatr 2014;35(8):475–485).

The 1-year PACT study of 152 children ages 2–4 years found positive treatment effects for parental synchronous response to children, children’s initiations with parents, and shared attention. Effects on language and adaptive functioning in school were small. Even more importantly, follow-up of 80% 6 years later had less severe overall symptoms at ages 7–11, improved social communication, and reduced repetitive behaviors, although did not affect language or anxiety (Pickles A et al, Lancet 2016;16(3):1229).

CCPR: Is there any other interesting research you’ve come across?
Dr. Wieder: Neuroscientists studying infant siblings of children with autism using MRIs, EEGs, and habituation measures of social attention identify autism before symptoms appear (eg, a study at 6, 12, 18 months offered siblings parent-mediated intervention). Promoting first relationships, between 9 and 11 months, found increased responsivity to social communication cues and contingent responding. The pattern of responses appeared closer to the normative response of 2 control, low-risk groups, suggesting parent-mediated intervention has the potential to impact brain systems underpinning social attention (Jones EJH et al, Autism Res 2017;10(5):961–972).

CCPR: Getting back to intervention, and since the approach relies on parents, how much time do they put in? And is this stressful for families?
Dr. Wieder: Parents of a child with autism or any other significant disorder experience stress and worry about their child’s outcomes. But DIR research and PACT parent reports tell us parents feel less stressed when they learn to be more effective and engaged with their children. Our intervention involves coaching, playing together, reflection, advocacy, and guiding other interventions. PACT uses video playback. Typically, parents (and other caregivers) offer “floor time” (the playtime of DIR) multiple times a day for 20- to 40-minute uninterrupted sessions, and they emphasize communication and problem-solving interactions throughout daily routines. We also stress lots of movement, play dates, and of course therapies and school. Floor time is both a method for interaction and a philosophy of engaging and relating to promote development. It gets integrated into family life.

CCPR: So, what types of questions should we be asking parents as part of the intervention?
Dr. Wieder: We respond to the concerns parents convey. For example, a dismayed parent unable to engage a child needs to talk about this and will become more open to coaching (eg, are you positioned in front of the child at eye level, talking too fast or too much, changing topics or toys too often, or not following the child’s interests?). A parent exasperated by avoidance or oppositional behavior may feel inadequate or be hanging on to hope. Perhaps the parent is confused, and we consider what the child’s behavior means, as well as what to do. We encourage mentalization and guide insight. For example, “How do you prepare for transitions or changes? What makes setting limits difficult?” Our job as clinicians is to strengthen sensitivity and the feeling of competence.

CCPR: It seems like a big shift, having parents so involved.
Dr. Wieder: I’m not sure it is. Parents raise their children and can carry over interventions daily. Some parents still wait outside the therapy room. We use in-session, in-the-moment interactions with parents to attend to feelings, engagement, or distress. We practice co-regulation and help the dyad calm and reconnect, while seizing moments of excitement and pleasure. We ask parents what they would like to experience and share their efforts. Following a child’s interests, expanding and deepening the “plot,” or overcoming hurdles is not always automatic. We might coach or model and alert the parent to anxiety or confusion, guiding at-home follow-up. With parents in the room, we are partners identifying challenges, highlighting strengths and progress, and providing strategies for home.

CCPR: Thank you for your time, Dr. Wieder.