The DIR/Floortime Model

1. The DIR/Floortime Model Leala Gonzales, LSW Assessing Autism Interventions June 10, 2010

2. Database Sources • Academic Search Premier • ERIC • MasterFILE • PsycINFO • PubMed • www.asatonline.opg • www.playproject.org • www.icdl.com • www.yorku.ca

3. The DIR/Floortime Model What is DIR/Floortime? • History • Developmental, Individual-based, Relationship Model • Six Developmental Milestones • Floortime What does DIR/Floortime claim to do? • Who does it address? • What does it do? What evidence supports the model? • Research • New Research Conclusions

4. History of DIR • Developed by Dr. Stanley Greenspan • During residency became interested in working with young children • Began his search for a new framework for understanding human development • As Director of Mental Health Study Center at NIMH created a dept. in clinical infant development • Synthesized what predecessors theorized looking specifically at affect, cognition, motor and sensory development • Followed children from “bottom-up” to develop an affect-based approach http://www.icdl.com/portal/node/53

5. DIR: The Developmental, Individual-based, Relationship Model Developmental • The building blocks of the Model • Understanding stage of development is critical to planning treatment • Six Developmental Milestones describe the steps of development that every child needs to master for healthy growth Individual differences • The unique biologically-based way each child takes in, responds to and eventually understands the world around him/her • Biological challenges that interfere with growing and learning http://www.icdl.com/dirFloortime/overview/index.shtml

6. Relationship-based • The learning relationship with caregivers, teachers, therapists, siblings, peers, etc. who interact with the child to master the stages of development http://www.icdl.com/dirFloortime/overview/index.shtml

7. Six Developmental Milestones • Self-regulation • Forming relationships • Two-way purposeful communication • Complex communication • Creating emotional ideas • Emotional thinking (Greenspan & Weidner, 1998)

8. Floortime Description – • Greenspan’s method of creating an environment based on play that engages a child by following their lead during activities of interest • Observes the child to clue adult into how to approach child • Strives to develop pleasure in relating to others rather than teaching a specific skill • Play is at the child’s level (focusing on strengths not deficits) • Extending or expanding the play by creatively intruding (to open circles of communication) physically or verbally • Encouraging the child’s interest in communication (verbal and nonverbal) • Stimulating the movement through the Six Developmental Milestones • Method used by parents (under direction of Floortime specialists) and other professionals • Can be done at home, in treatment centers, in school (Heflin & Simpson, 1998) (Metz, Mulick, & Butter, 2005)

9. Floortime Components Home-based – Heart of the program is this component to allow practice of skills in the naturalistic comfort and security of the home • Up to eight 20-30 minute sessions daily are optimal • 25 hours/week Therapeutic Team – Speech therapy, Occupational therapy trained in SI, Physical therapy • Three or more 45 min. sessions/week depending on individual differences Educational Program – Integrated small class (up to 3 special needs children) • Special education teacher, early childhood teachers • Therapists coming into class http://www.icdl.com/dirFloortime/overview/GuidelinesforComprehensiveApproach.shtml

10. What does DIR/Floortime claim to do? • Who does DIR/Floortime address? ASD Down Syndrome Severe ADHD Cerebral Palsy Fetal alcohol Syndrome Communication delay regulatory problems

11. What does Floortime do? • Finds the parts of central nervous system that create developmental challenges and working to improve them: Sensory system- taking information in from the world through our senses Processing system-making sense or interpreting of the information received through the sensory system Motor system- physically responding to that information (Greenspan & Weidner, 1998) • Move child along the developmental ladder • Assessment of growth is measured using the FEAS (Functional Emotional Assessment Scale) by looking at the child’s ability to: • Organize play interactions with persons and objects • Self-regulate mood and attention • Form attachments to caregiver • Engage in reciprocal emotional interactions and communications • Represent feelings and ideas and engage in emotional thinking through play interaction http://www.icdl.com/dirFloortime/research/FunctionalEmotionalAssessmentScale.shtml

12. What evidence supports the model? Pilot Study of a Parent Training Program for Young Children with Autism. The PLAY Project Home Consultation Program • Sixty-eight children completed 8–12 month program • Parents delivered 15 hours per week of 1:1 interaction • Pre/post ratings of videotapes by blind raters using the Functional Emotional Assessment Scale (FEAS) showed significant increases (p ≤ 0.0001) in child subscale scores. Translated clinically, 45.5 percent of children made good to very good functional developmental progress. • No significant differences between parents in the FEAS subscale scores at either pre or post intervention • All parents scored at levels suggesting they would be effective in working with their children. • Overall satisfaction with PPHC was 90 percent • Despite important limitations, this pilot study of The PLAY Project Home Consulting model suggests that the model has potential to be a cost-effective - Average cost of intervention was $2500/year. • Weaknesses: More measures of development are needed (IQ, language) • Inaccurate estimates of interaction time by parents • Did not study if outcomes would generalize to other environments (Solomon, Necheles, Ferch, & Bruckman, 2007)

13. Evaluation of the efficacy of a seven week public school curriculum based on DIR/Floortime parent training program for parents of children on the autism spectrum • Investigated the effectiveness of a 7 week DIR/Floortime parent training on: • Quality of parent-child dyad • Child’s developmental level • Assessed using: • Functional Emotional Assessment Scale (FEAS) • Neuro-Developmental Disorders of Relating and Communication Functional Emotional Development Levels (NDRC-FEDL) • Results: significant in both quality of dyad and increased developmental level (Pilarz, 2009)

14. Developmental progress of children with pervasive developmental disorder and/or sensory processing disorder enrolled in a DIR/Floortime therapy group • Longitudinal study of 20 children diagnosed with PDD and/or SPD • Conducted at a pediatric therapy clinic • Participants were from a DIR/Floortime based developmental play group • Pre and post tests (13.5 month intervention) using Sensory Profile • Studied developmental progress after intervention regarding age, time spent in intervention, differences between the two ICDL diagnostic categories: regulatory-sensory and neurodevelopmental disorder • Results: • No statistical significance found when age and time spent in intervention were examined • When diagnostic categories were compared, the neuroevelopmental group “moved toward a typical range of functioning” according to Muritidis. • Cannot be used to generalize to the greater population due to the limited number of participants (Muratidis, 2009)

15. Brief Report: Comparative ABA and DIR Trials in Twin Brothers with Autism • The parents of identical twin brothers interested in both approaches -age 2.4 years -diagnosed with severe speech-language delays and autism • Agreed to a pilot study of short-term interventions at James Madison University in Harrisonburg, VA • Each worked with a graduate level speech-language pathology clinician under supervision of one of the authors (holds a national certification in speech language pathology and teaches interventions in autism at the graduate level) • Each attended 16 of 18 sessions, missing two due to illness • The Communication and Symbolic Behavior Scales (Weatherby and Prizant, 1999) were used to test them at the initial and final sessions • Scored by clinicians and then by their supervisor to ensure accuracy • The boys also were provided speech therapy services at their school twice a week, but neither ABA nor DIR programs were used (Hilton, & Seal, 2007)

16. Weekly conferences between clinicians and supervisor took place and included: • A review of at least one videotaped session per week • A review of the supervisor's observation notes • Discussion of each boys interventions regarding implementation of treatment, activities for the session and issues of behavior • Plans for each session with boys coordinated using similar toys, books and snacks • Data was tallied by graduate students (who did not know the boys' diagnoses nor the interventions) viewing videotapes regarding vocal, gestural and verbal responses to communication opportunities and negative behaviors • No other data taken to validate appropriate application of DIR and ABA- putting into question some treatment integrity (Hilton, & Seal, 2007)

17. Limitations of study: • Did not employ the intensive treatment time commitments typical of both interventions • The outcome was based solely on the results of the CSBS • The impact of possible differences in each clinician's skill level in the intervention program • Generalizing the results to other individuals is guarded (Hilton, & Seal, 2007)

18. Can Children with Autism Master the Core Deficits and Become Empathic, Creative, and Reflective? A Ten to Fifteen Year Follow-Up of a Subgroup of Children with Autism Spectrum Disorders (ASD) Who Received a Comprehensive Developmental, Individual-Difference, Relationship-Based (DIR) Approach By Dr. Stanley I. Greenspan & Dr. Serena Wieder (2005) • Follow-up study of 16 children diagnosed with ASD • Using DIR/Floortime approach • Results: • a subgroup of children with ASD can become empathetic, creative, and reflective, with healthy peer relationships and solid academic skills. This • suggests that some children with ASD can master the core deficits and reach levels of development formerly thought unattainable http://www.icdl.com/dirFloortime/research/index.shtml

19. Relationship Focused Early Intervention With Children With Pervasive Developmental Disorders and Other Disabilities: A Comparative Study • Study by Mahoney and Perales (2005)compares the effects of relationship-focused early intervention on toddlers and preschool-age children who were classified as PDDs (N = 20) or developmental disabilities (N = 30) • Conducted over a 1-year period • Weekly parent-child sessions focused on showing parents to use responsive teaching strategies to encourage children to acquire and use pivotal developmental behaviors that addressed their individualized developmental needs • Results: • Before/after comparisons indicated significant increases in parents’ responsiveness and children’s pivotal behavior • Both groups of children made significant improvements in cognitive, communication, and socio-emotional functioning • Children with PDDs made statistically greater improvements on the developmental measures than children with DDs. • On several developmental measures, children’s improvements were related to increases in both their parents’ responsiveness and their own pivotal behavior http://www.icdl.com/dirFloortime/research/index.shtml

20. Educating Children with Autism” (National Academy of Sciences, Committee on Educational Interventions for Children with Autism, NRC, 2001) • Cites ten programs with some evidence of being effective • three -based on developmental, relationships, and family support • two -highly structured behavioral programs; and • four -combined elements including a movement toward more naturalistic teaching methods • There is research support for a number of approaches, including DIR/Floortime and behavioral interventions • There are no proven “relationships between any particular intervention and children’s progress” (p. 5) and “no adequate comparisons of different comprehensive treatments” (p. 8). • NAS (2001) analysis further notes that “studies have reported that naturalistic approaches are more effective than traditional discrete trial at leading to generalization of language gains to natural contexts.” • These behavioral approaches are becoming more similar to developmental, relationship-based models with the goal of creating learning relationships that build on a foundation for relating, communicating, and thinking. http://www.icdl.com/dirFloortime/NASRreport.shtml http://www.icdl.com/dirFloortime/NASRreport.shtml

21. Developmental Patterns and Outcomes in Infants and Children with Disorders in Relating and communicating: A Chart Review of 200 Cases of Children with Autistic Spectrum Diagnosesby Stanley I. Greenspan, M.D., & Serena Wieder, Ph.D. (1997) • Charts of 200 children who were diagnosed with autistic spectrum disorder were reviewed • Goal of the review was to reveal patterns in presenting symptoms, underlying processing difficulties, early development and response to intervention in order to generate hypotheses for future studies • The review suggests: • a number of children with ASD are, with an appropriate intervention program, capable of empathy, affective reciprocity, creative thinking, and healthy peer relationships • an intervention approach that focuses on individual differences, developmental level, and affective interaction may be especially promising • that there are different underlying processing patterns with a difficulty in connecting affect and sequencing capacities as a possible common denominator • difficulties with relating and intimacy are often secondary to underlying processing disturbances. http://www.icdl.com/dirFloortime/research/index.shtml

22. New Research September 2009 - the NIMH awarded the P.L.A.Y. Project a $1.8 million grant for a controlled trial of play-based autism therapy. • Conducting the 3-year study: Richard Solomon, MD • Research-design guidance: Michigan State University, and community-outreach support from Easter Seals • Clinical Trial: randomized, controlled, and blinded • Participants: five Easter Seals autism service locations • Compares the outcomes: 60 children who participate in The P.L.A.Y. Project to of 60 children who receive standard, community interventions • Before /after (12-month intervention) assessments to measure: developmental level, speech and language, sensory-motor profile, and social skills • Largest study of its kind http://www.playproject.org/about_research.php

23. New Research con’t The P.L.A.Y. Project • P.L.A.Y. was developed by Dr. Solomon • Application of DIR/ Floortime framework • “Through structured monthly home visits focused on modeling, coaching and video feedback, consultants train parents to engage their child with autism in ways that promote emotional connection and communication. By training parents to participate in their child’s intervention, the program also promises to be cost-effective. The P.L.A.Y. Project costs under $4,000 per year, in comparison with other interventions that cost $40,000 to $60,000 per year.” http://www.playproject.org/about_research.php

24. New Research con’t York University in Toronto, Canada • 2005 Received $5 million to establish a research initiative from Milton and Ethel Harris • Stuart Shanker, research professor of psychology and philosophy, will work with a research team • Stanley Greenspan, chief advisor http://www.yorku.ca/yfile/archive/index.asp?Article=4712

25. The last word from ICDL “There is a wide range of research and clinical experience not just from the field of autism but from the field of early intervention and child development at large, which, when taken as a whole, provides considerable empirical support (far more than for more circumscribed approaches) for a comprehensive developmental model.” http://www.icdl.com/bookstore/catalog/documents/p1(1234).pdf

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27. Conclusions “Although Floortime is an approach that holds promise for engaging children with autism and promoting their ability to relate to others, more empirical research is needed.” (Heflin & Simpson, 1998, p. 211) “ Based on scientific research to date, there is not enough evidence to conclude that DIR is an effective treatment for children with autism." (Freeman, 2007, p. 141) “Level of research support was found to be Emerging (one or more studies indicate favorable results, more studies are needed to determine the intervention is effective).” (National Standards Project, 2010, p. 20)

28. Conclusions con’t • In Interventions for Autism Spectrum Disorders: State of the evidence (A collaboration of the Maine Department of Health and Human Services & the Maine Department of Education) October 2009 • Established six levels of evidence: Level 1: Established Level 2: Promising Evidence Level 3: Preliminary Evidence Level 4: Studied and No Evidence of Effect Level 5: Insufficiently Studied Level 6: Evidence of Harm • DIR/Floortime falls under Level 5: "Conclusions cannot be drawn on the efficacy of the intervention due to a lack of quality research, or mixed results in several studies.” http://www.asatonline.org/pdf/winter2010.pdf p. 3

29. Conclusions con’t Metz et al (2005) stated, “ The lack of empirical support is unfortunate because, although this form of intervention remains unsupported, we find elements of the Floortime intervention of interest. At it’s core the model seems to incorporate an intensive form of incidental teaching, creating and capitalizing on interaction and instructional opportunities and teaching new skills using shaping and reinforcement. These concepts of intervention are important to teaching and generalization of skills that should be an integral part of any intensive intervention program. The emphasis on increasing parent sensitivity to, and in practice and generalization of skills in natural setting is one, in our experience, that is occasionally missing from many home intensive intervention programs based on principles of applied behavioral analysis." (p. 258)

30. Questions????

31. References Freeman, S. K. (2007). The Complete Guide to Autism Treatments. Lynden, Wa.: SKF Books. Greenspan, S. I., & Weidner, S. (1998). The Child with Special Needs. Reading , Ma.: Perseus Books. Heflin, L., & Simpson, R. (1998) Interventions for Children and Youth with Autism: Prudent Choices in a World of Exaggerated Claims and Empty Promises. Part I: Interventions and Treatment Option Review. Focus on Autism & Other Developmental Disabilities, 13 (4) , 194-211. Retrieved from MasterFILE Premier database Hilton, J. C., & Seal, B. C. (2007). Brief Report: Comparative ABA and DIR Trials in Twin Brothers with Autism. Journal of Autism & Developmental Disorders, 37 (6), 1197-1201. doi:10.1007/s10803-006-0258z Metz, B., Mulick, J. A., & Butter, E. (2005)Autism: A Late 20th Century Fad Magnet in Jacobson, J. W., Foxx, R. M., & Mulick, J. A. Controversial Therapies for Developmental Disabilities: Fad Fashion, and Science in Professional Practice. (pp.237-264) New York: Ruetledge. Muratidis, H. (2009). Developmental progress of children with pervasive developmental disorder and/or sensory processing disorder enrolled in a DIR/Floortime therapy group (Doctoral dissertation ,Adler School of Professional Psychology, 2009). Proquest Dissertations And Theses, Section 1143, Part 0622. National Autism Center. (2009). National Standards Project Findings and Conclusions. Randolph, Ma. Pilarz, K. (2009) Evaluation of the efficacy of a seven week public school curriculum based on DIR/Floortime parent training program for parents of children on the autism spectrum (Doctoral dissertation, Temple University , 2009) . Dissertation Abstracts International, 69, 122A. Solomon, R., Necheles, J., Ferch, C., & Bruckman,D. (2007). Pilot study of a parent training program for young children with autism. Autism 11 (3), 205-224.

32. References http://www.asatonline.org/pdf/winter2010.pdf http://en.wikipedia.org/wiki/Ego_psychology http://www.icdl.com/bookstore/catalog/documents/p1(1234).pdf www.icdl.com/dirFloortime/overview/index.shtml http://www.icdl.com/portal/node/53 http://www.icdl.com/dirFloortime/overview/DevelopmentalMilestones/Stage6.shtm http://www.icdl.com/dirFloortime/overview/GuidelinesforComprehensiveApproach.shtml http://www.icdl.com/dirFloortime/research/FunctionalEmotionalAssessmentScale.shtml http://www.icdl.com/dirFloortime/overview/index.shtml http://www.icdl.com/portal/node/53 http://www.objectrelations.org/orkey.htm http://www.playproject.org/about_research.php http://www.yorku.ca/yfile/archive/index.asp?Article=4712