42 months old girl, U. Only child of academic parents – father, physicist, works primarily at home for a start-up,
mom, anthropologist, in (very stressful) tenure process at University. Of medical significance is family history
of psychiatric issues, specifically mild chronic depression of both U.’s parents, as well as mental illness on
paternal grandfather side, with paternal uncles having difficulties possibly on the Autistic spectrum. U.
underwent testing at the end of 2009, and was given diagnosis of PDD-NOS. Since January 2010 she is
attending an integrated classroom and has adjusted well.
I have been seeing U. for about 6 or 7 months. For the first few months Mom attended sessions, and for the last
two months, she has been coming to therapy with her baby-sitter.
Functional Emotional Developmental Capacities:
U. has a scatter of abilities and can stretch, on a good day, all the way to level 4, possibly 5: Due to sensory-
motor difficulties, she still has difficulty in Self-Regulation and Shared Attention. When overwhelmed
sensorally or emotionally, or when struggling with motor planning, she will either whine anxiously, or withdraw
and play by herself. Although she has made great strides in this area (when we first met, she couldn’t stay in one
room, and would only be able to sustain interest in one play scenario for 2-3 minutes at most. She now is able to
remain in one area for 20-30 minutes, and sustain attention, including joint-attention, for 15-20 minute spans).
She has shown growth in her ability to engage and relate (Level 2), and is able to co-regulate much more
effectively, and use an empathetic adult to aid her with maintaining focus and attention. Again, sensory
difficulties and motor planning challenges sometimes come in the way of engagement. Level three is probably
where U. is best able to function when she is engaged and self-regulated. Language constrictions, including pre-
verbal language abilities (both reading and expressing non verbal communication through, e.g. gestures or affect
cues) inhibit her ability. Though U is verbal, she has an expressive and receptive speech-language delay and
slowed processing that frequently causes the chain of communication to break. Affect cueing is reduced, so that
she doesn’t always communicate effectively non-verbally. When the three first stages are in place, U is able to
create little play sequences. Lately, she has been enacting preschool activities, going to the doctor, etc. Her
ability to create representational play is, however, constricted and repetitive. She shuts down when too much
language is involved (e.g. when confronted by wh-questions), or when I try to climb the symbolic ladder too fast
(which is one of my challenges when I play with her), or, frequently, when sensory-motor constrictions reduce
her abilities in the foundation FDLs (levels 1 through 3). U has a hard time when I try to gently push her into
stage 5, though she is showing glimpses of this ability, and enjoys high affect and silliness, if it is done slowly,
and if her adult play-partner is able to respect her Individual Differences.
U has many sensory difficulties, has slowed processing abilities for incoming sensory information and
difficulties with SI. She has difficulty with visual processing (she will spend several minutes looking for a
specific toy that is right in front of her), auditory processing (including receptive language), she sometimes
cringes from touch, and sometimes finds hugs organizing and soothing. She is often moving around the room in
what I call her “Raggedy Ann” walk (not a DIR term, but an accurate description nonetheless), stepping on toys
and bumping into objects. Motor planning is challenging for her, and getting a doll dressed or undressed can
sometimes be challenging (and disregulating) for her. She often has a worried or anxious affect.
She has a large vocabulary (knows colors, shapes, the alphabet), and speaks with a mixture of scripted and
echolalic sentences. Her spontaneous speech is growing, however, and self-generated speech shows significant
delays in syntax and morphology (e.g. pronouns) and limited repertoire of sentence types.
She is potty trained, but still has almost daily accidents, especially with bowel movement, and gets agitated
when I suggest she go to the bathroom.
U has a warm relationship with her parents and caregivers (e.g. other close family members, baby-sitter). She
clearly prefers her mother over anyone else, and positively glows when Mama comes to therapy and they have
their special “mama U” afternoon. Unfortunately, “Mama” has a particularly demanding work load, and is in
constant struggle to spend enough time with U. Lately (last 3-4 weeks), U has shown a lot of anxiety around
missing Mama, and this has been a recurring theme in our sessions as well.
Vignette 2: NC
NC is a six year old boy who attends kindergarten at a public school. His family relocated from Israel in August
2009, and I started seeing him shortly after they settled in. He has no known diagnosis. He underwent a speech-
language evaluation here by a bilingual SLP who found delays in expressive language (organization, narrative
and word retrieval), as well as mild articulation delays (/s/, /z/ and /sh/ sounds). He lives at home with stay at
home Mom, a father who has long working days, and his two sisters (9 years old and 8 month baby). He had
seen a psychologist for a while when in Israel, due to some anxiety and general “sensitivity”. This therapist
recommended that the family not address language difficulties due to N’s “sensitive” nature. He also had seen
an OT. He is due to have testing by a Hebrew speaking psychologist through the Public Schools. He is having a
hard time socially, but its unclear how much of this is due to his slow ability to pick up English, and how much
is pragmatic difficulties.
Functional Emotional Developmental Capacities
NC functions primarily around level 4 and has constricted abilities in level 5 and 6. He is fully verbal, and can
maintain long reciprocal interactions and discussions about a variety of topics. He has constricted imaginary
play, and a small range of emotional themes. Aggression is the predominant theme in his play, and he is usually
unable to answer “why” questions or elaborate, with language or affective cues, nor is he able to create a logical
sequence to his play. His play is either physical (e.g. he enjoys bouncing and balancing on a large inflated
pillow), or repetitive, constricted and rather concrete play of “bad guys” (usually black plastic soldiers) against
“good guys” (the grey ones) which he bangs against his other making loud crashing and weapons sound effects,
and where everyone “dies”. When in gross motor movement, his affect is excited and happy, and he enjoys
having an adult play with him. His ability to problem-solve and connect ideas, though limited and requiring
adult support, is at its best in these moments. After about 20 minutes or so, he typically will stop this game. He
will then move on to playing with toy soldiers. Motor planning difficulties may be inhibiting more elaborate
play. When engrossed in this type of play, he has difficulty letting an adult player in, and will “ignore” questions
He has a hard time coming up with ideas and initiating play, as well as more abstract and emotionally elaborate
problem solving, and will often roam the clinic room asking repeatedly, ”what should we play?”
It is challenging to work with NC because he has such a mixture of abilities – verbal and engaged on the one
hand, yet restricted, concrete and monotonous in his play, on the other. I am still getting to know him and how
high he can be “stretched”, given his language and motor planning difficulties.
NC has significant motor planning difficulties. His difficulty to ideate and create a scheme in his mind interfere
with his ability to play, and, in turn, affect his word retrieval abilities as well (he has both phonological
difficulties in retrieval and semantic difficulties, and has challenges with creating a “picture in his mind” to aid
with retrieval). NC is aware of his language difficulties, both in terms of articulation (slight frontal lisp) and in
terms of word-finding, and will often respond with “I don’t remember” when asked to name something or recall
a verbal detail. He is easily frustrated and is reluctant to try what he perceives as new or challenging things.
His thinking and language abilities are concrete, and he has difficulty perceiving multiple meanings.
NC has difficulty with auditory processing, and sometimes appears to be “ignoring” an adult when language is
too fast or to complex. His voice is somewhat flat.
Although not observed with peers, he does present with pragmatic difficulties, so that, coupled with somewhat
slow language processing abilities, he probably has difficulty keeping up with fast paced play of peers. He is
now struggling with acquiring English as a second language, which is coming slowly, probably due to delays in
his first and native language, Hebrew.
He has a warm relationship with his mother and sisters. Mom is very protective of him, and is clearly committed
and is an active participant in therapy sessions. She struggles with finding alone time with NC. Dad will start
coming to sessions once or twice a month, but has not yet started this. Per report, he loves rough housing with