This Week’s Podcast

This week’s podcast features DIR Expert Nagwa Khedr, who is an early intervention specialist in Cairo, Egypt. She’s been practicing DIR/Floortime since 2014 and was involved recently in opening a DIR/Floortime Center there called Etwasel, which means ‘Connect‘ in English. We met in person last year at the in-person DIR International Conference in New York City and have been planning to do a podcast ever since. Our topic is affect and regulation in the Middle Eastern culture as part of the ‘I’ in the DIR Model, Individual differences.

Affect and Regulation in Middle Eastern Culture

by Affect Autism

‘Fluorescent’ Affect

Nagwa says that in the Arabic culture, in general, the affect is big! The voices are loud, and people use their hands, facial expressions, and gestures when talking. They are very emotional and are very close to each other, physically. In DIR, affect can be changeable, Nagwa explains. You don’t always have to use affect the same way. This was a challenge when learning about Floortime, she admits. To them, affect is about praise. Affect is about the way you praise a child such as saying, “Well done! You did a great job!” with positive enthusiasm in your voice.

Nagwa explains that in DIR you tailor your affect to the child’s D and I, so it’s not a generic way of interacting with everyone. This was a challenge to adapt to in their culture. It is a challenge explaining it to parents, she says, how you can change your affect depending on your child. I shared an example of an Arabic mother from Lebanon I knew who held a very firm affect with her children that was a very limit-setting type of affect that I admired. 

Parenting Style

Nagwa says that this is very similar to the culture in Egypt. She says that in Middle Eastern culture there is even a joke about this: you give the child ‘the stare’ to make them comply, but this lacks the R component of DIR, the Relationship, she explains. It’s not about connection, but about looking at the child and expecting them to stop what they are doing. Parents there get frustrated when they do ‘the stare’ and the child doesn’t stop, Nagwa shares.

This is the way that many were raised in her culture, Nagwa shares, and if your child isn’t listening to you or stopping when you do ‘the stare‘ it reflects on you as a parent–that you’re doing something wrong. It’s a very prevalent parenting style, so she has to begin to explain how to interact differently to parents.

Focusing on the child

Nagwa starts by having the parents look at their child as a unique individual with their own strengths and challenges that need support. She explains that you can’t just having a generalized way of parenting or having a generalized affect that will work with anyone. She will look at the child’s individual profile and have the parents in the session with them, seeing them play with the children, modelling how affect could look like, and having them reflect on why their child does certain things in play. Just telling the parents to “stop it” won’t help, just as staring at the child won’t make the child stop, Nagwa asserts.

Family structure

Nagwa explains that the family structure in the Middle East is very different than in Europe or North America, with the extended family being more involved. Even though the caretaking does mostly fall on the mother, it’s not just children and their parents. The grandparents, in-laws, and even aunts, uncles, and cousins are all together. Many families live in the same building and go in and out of each other’s homes. The pressure does fall on the mother, though, as their role is the most powerful for the children and their progress.

Supporting Regulation

When Nagwa tries to coach the parents, which is usually the mother, it’s hard because when they go back to the big family, they expect the child to comply. People still believe that regulation is compliance. If the child is not complying, behaving, or sitting still, it means they are dysregulated and needs more discipline. I asked Nagwa how she supports the mother’s regulation. They created a course for mothers to look at their own individual profiles, since they always speak to them about their child’s individual differences.

It’s never because you’re a bad mother, or too busy. You need to regulate first. We can’t regulate our children if we, ourselves, are not regulated. They try to let mothers know that they need regulation as well. They explore what makes them regulated and what triggers dysregulation? Do they have a co-regulator like a pet or a friend to help with their regulation? I wondered if maybe that can be easier in a collectivist culture since the mother has a larger family support system.

Nagwa says that while it can be a blessing because so many people will come to help and support you, many parents say that they wish they had more space for themselves so they can establish a routine for themselves since they are a very behaviourally dominated country. Explaining to family members about sensory and other needs can be very hard, because the family might believe that the child is just being spoiled. It can be hectic to have everyone involved in their lives.

Nagwa finds that the best method is to help parents to be more reflective in their own way. They can figure out why they did something, which is better than her just giving them ‘strategies’. Again, it is mostly the mothers, even though the fathers sometimes come in for the meetings. When you see a playful father, people often envy the mother for having such a helpful husband since the father is usually working while the mother takes care of everything else.

Focusing on Affect and Attunement

Nagwa tries to fit the affect with the child’s individual differences. It might mean speaking more quietly or slowly. It might be adjusting their cadence. It’s about taking the cues from the child. If the child is withdrawing from the interaction, figure out how to entice them back in by experimenting with your affect. Parents often tell her that they are doing it, but it tends to just be them praising the child rather than connecting and interacting with the child. She tells them to pause and observe.

Attunement in their culture, Nagwa explains, is different. She finds that when a mother is very attuned to her child and a good advocate, people tend to judge that the mother is making excuses for her child. People don’t really ‘get’ attunement. Mothers hear from other therapists that they, the mothers, don’t really know–that they, the therapists know better and the mother is just spoiling the child or making excuses. It causes the mother to not trust her own intuition, Nagwa suggests. She thinks that maybe her child is just being manipulative.

I commented that this must produce feelings of guilt in the mothers, and shared that I covered this topic in my podcast with Dr. Kathy Platzman, Avoiding the blame in Floortime.



Most schools there are behaviourally-based, Nagwa shares, and that most kids have an aid with them in the school. Nagwa tries to foster good relationships between parents and school personnel. She also explains that how we say things impacts another’s understanding. When we don’t have strong relationships with schools, things can fall apart, she says. Even when people are convinced, the teachers might say, “But it takes longer“. It may take longer, but the results are amazing, Nagwa reflects.

When they focus on connection and regulation, they see that it makes sense. Many of the teachers have taken DIR 101: An Introduction to DIR and DIRFloortime.


Making Sense of the Model

Nagwa says that the people in her country are very emotional, so it helps when they learn about the Functional Emotional Developmental Capacities (FEDCs) in the DIR Model because it makes sense to them. They want their children to have these emotional capacities. They tend to open up and share many things with others in the culture. Nagwa tells them to share their emotions with their children and to let the children see their emotions when you’re playing and interacting with them. It isn’t just about being happy all of the time.

Nagwa says that it’s about how they guide parents that makes the difference. Many parents have had other therapies before with their child that have taught them not to show emotions and to just give praise. When she explains fostering emotion, it makes sense to them not to ignore emotions. I asked if it was socially inappropriate to be that way in school or in public. Nagwa says that lately they have done awareness campaigns, but the stigma of having any diagnosis is still there.

Nagwa tries to foster a strengths-based approach. Still, mothers report a fear of being in public with their children with their friends because they’re embarrassed if their child has a meltdown, wears headphones, or stims. Everyone is involved in each other’s life so you will get a lot of stares and questions from others. Nagwa focuses on how to support each other versus judging each other, because they often like to tell each other what to do.



Opening their DIR centre, Etwasel, was a challenge at first because people wanted to ‘fix’ their children versus looking at the children holistically, Nagwa shares. They are seeing parents who are getting the idea and are more committed. They are taking baby steps, and like Special Educator, Jackie Bartell says, they are doing it one-by-one-by-one.


Research on Autism and the Middle East

I mentioned that the OCALICONLINE conference last November, there were a few studies on parenting and autism in a few middle eastern countries (here and here) and I wondered if Nagwa knew of any research going on there. Nagwa says they have been supporting research going on there and have flyers for their clients to participate. There is a current study on attachment they are recruiting for that is developmental in nature, while most of the research in the country is still behavioural in nature. 


The Parent Journey

Nagwa recalls a family who embraced Floortime and how she started playing with a child who had strong emotional reactions and with whom the parents struggled to interact with. The mother noticed that the child was interested in Nagwa when they were playing together. It hooked the mother into Floortime. There was a lot of focus on emotional regulation, which is hard when they typically focus on cognitive or sensory strategies. The mother attended the sessions and started playing herself because she saw how much the child enjoyed the sessions.

The mother became very interested in DIR and read Engaging Autism. She would share what happened in school and share how it was going at home. When she saw the spark in her child and the progress, she was convinced about using DIR/Floortime. Nagwa says it’s about celebrating the process. When they shift from goals and outcomes to noticing how much the children can do and the process, they start to appreciate it and realize the approach is working. At that point, family members come on board, too.


Services in Cairo

Nagwa says that there is Occupational Therapy (O.T.) there, but there is not a school for it, so many of the O.T.s are Jordanian, Palestinian, or Lebanese. The norm when a child is diagnosed is to get a behavioural therapist. O.T.s are not as much a part of it as it should be. They do have an O.T. at Etwasel. They see the children who require O.T. services, especially in the schools. They also have many speech therapists.

Nagwa teaches the introductory course to DIR in Egypt person because most of the teachers and parents prefer to be there in person to meet others and to ask questions. She also taught the course in Jordan, as well. It’s typically O.T.s and SLPs who take the courses, she says. 


Presence of Self-Advocates in Egypt

Nagwa says that there are a few Instagram accounts by self-advocates that are in Egypt, but not many. They are very helpful, especially to parents, to see examples of adult autistics. 

This week’s PRACTICE TIP:

This week let’s think about cultural differences and how they can impact our interactions with our children.

For example: Does your culture expect compliance from children over all else? Academics? How does the affect within your culture vary from where you live if you are living in a country different from where you had your childhood? Do you have cultural expectations for your child that make Floortime challenging?

Thank you to Nagwa for giving us insights into practicing DIR in the Middle Eastern culture. We hope you found it very enlightening and will consider sharing this post on social media. 

Until next time, here’s to choosing play and experiencing joy everyday!

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