Guidelines for a Comprehensive DIR Program

For children who have significant challenges in relating and communicating—often diagnosed with autism spectrum disorder, or a multi-system developmental disorder—a comprehensive DIR program begins with a comprehensive assessment process that seeks to understand the complete individual profile of the child.  The assessment needs to look beyond simply symptoms and diagnosis.  The assessment needs to look at the whole child and all of their individual differences. 


The cornerstone of a DIR Program is Floortime.  However, it is not limited to just Floortime.  Occupational therapy, speech therapy, physical therapy, counseling, biomedical treatments, parent support, educational services, and other appropriate therapies should be employed as part of the DIR Program.  All therapies should be provided in a coordinated, interdisciplinary DIR-based manner that supports the overall development of the individual.   


A comprehensive approach comprises many elements, but the cornerstone is the home Floortime program. For the more severe and challenging problems, six to ten 20 to 30 minute Floortime sessions every day is optimal. Following this program often means determining how much each parent can do and how much help is needed. Help can include siblings; other family members; a graduate student in speech pathology, occupational therapy, or education; high school students; neighbors; or volunteers. Individuals working with the child on Floortime need a natural ability to relate and interact and a capacity, with experience, to master the guidelines described earlier. Parents or therapists typically need to train other helpers.


There are many hours in the day. If the child spends too large a portion of his day involved in self-absorbed activities, self-stimulation, or one-way communication, such as watching TV, he won't have the practice he needs to learn essential skills. The child's progress is generally proportional to the amount of energy and time spent in the trenches, with someone wooing and pulling him into Floortime interactions.


As the child becomes more verbal and capable of building bridges between ideas, it's important to add reality-based problem-solving discussions to the daily routine. This type of dialogue may be about school, friends, favorite foods, toys. The child also needs help in anticipating challenges that may emerge later in the day or the next day. As the child becomes more logical, six steps—involving Floortime, problem-solving time, empathy for the child's perspective," breaking challenges into small component parts, setting limits, and doing extra floor time when there's a need for extra limits—should become a part of the daily routine.


It is also important to tackle the problems that the newly logical child has graduated into, such as pulling toys away from friends, wanting his own way all the time, being clingy or demanding, and so forth, by providing extra practice in the situations that bring up the problematic behavior. Parents may want to avoid certain situations, such as those requiring sharing, because their child has trouble with appropriate behavior. The child then continues to misbehave in school or in play dates because those are the settings in which the situation he can't handle arises. By creating similar, controlled situations at home under their guidance, parents can provide extra practice, for example, in learning to share or not to crowd others and get into their body space. When parents are helping their child, they can use problem-solving strategies, such as talking it through, rehearsing, and practice, and they can provide structure, limits, and encouragement. The key is gradually to practice the skills that need to be mastered in the comfort and security of the home, rather than avoid situations or expect the child somehow, magically, to master the skills on his own.


Children with special needs, in order to learn to relate, communicate, and think, often require extra practice. As they graduate into the arena of more subtle problems, such as controlling aggression, competitiveness, or jealousy or learning to respect others, the same principle of extra practice applies. Sometimes, rather than seeing these new challenges as relatively little ones in comparison to the bigger challenges of relating, communicating, and thinking, parents and educators become discouraged when the child who is now talking and relating does not operate as the perfect, well-mannered child. Helping children use their new thinking and communicating skills to master these more advanced challenges will give them a lifelong capacity to cope and learn.


Once they are capable of long, interactive sequences (complex gestural communication) and the beginning levels of pretend play or using words purposefully, it is critical for children to have lots of opportunities to practice their skills, not only with adults, but also with peers. Children benefit from three to four play dates a week with a child of the same age, plus or minus a year or two (as long as the playmate can communicate at or above the child's level). Beginning peer play early, often mediated or facilitated by a parent or other adult, helps children practice their new skill and become used to peers. Participating in and enjoying peer relationships will help children later on fine-tune and further develop their interactive and intellectual skills.


Siblings can also be part of the home-based program. Parents may need to help. For example, if a three-year-old with special needs isn't yet talking and his five-year-old sibling is doing complicated pretend play and talking up a storm, parents may need to pull in the nonverbal three-year-old, perhaps helping him move his truck or doll or hiding with him in the hide-and-seek game. When the nonverbal three-year-old is the leader, parents can help the older sibling set up a road block or other hazard for the three-year-old to negotiate.


In addition to home Floortime and peer play, another cornerstone of a comprehensive program is the team of therapists who work on the different component parts of the child's mind that are contributing to the difficulties. This team may include a speech pathologist to help with receptive and expressive language. An optimal program may involve speech therapy in individual sessions one-half to one hour long three or more times per week. An occupational therapist trained in sensory integration may be needed to work on sensory modulation, sensory processing, and motor planning in one-half to one hour sessions two or more times per week. Children with significant motor problems may work with a physical therapist several times per week. Meanwhile parents need to incorporate language, sensory-modulation, sensory-processing, and motor-planning activities into their spontaneous Floortime.


Finally, many children benefit from being in an educational program.  The optimal educational program, in addition to providing services for children with special needs, also provides access to other children who are very interactive and have spontaneous communicative skills. Thus as the child with special needs begins to interact and communicate, he has peers who can interact and communicate back. When children with the same problem are grouped together in one program the problem is sometimes compounded because as one child becomes ready to interact, the other children are not available to harness that interaction and respond in return. Integrated programs that enable children with special needs to interact with children who don't have special needs or who have medical or learning problems that do not limit communication and interaction are very important.


A cautionary note should be inserted here. A program that does not have adequate staffing but uses the concept of integration as a way to reduce costs by placing 20 children with two teachers generally does not work and is not truly an integrated program. A successful integrated program should have a small number of children, perhaps three children with special needs, in a class with agemates without special needs. Special educators should be in the classroom, and speech and occupational therapists should be available either in the class or on a consulting basis. In some situations, early-childhood educators may be appropriate staff, with a special educator available in a consulting or part-time role.


Depending on family patterns and family stress and on the parents' comfort and skill in implementing Floortime approaches, it may be helpful for a developmentally based therapist to consult with the family on facilitating Floortime interactions in the home-based program. This therapist or another with knowledge and experience in assisting families and couples in their relationships may also help a family or a couple work through their challenges. It may be beneficial for a developmentally based floor-time therapist to work directly with the child one to four times a week, in addition to consulting and observing different family members engaged in floor-time interactions. With some families, these two pieces are integrated; the floor-time therapist works directly with the child while the parents are there, and then the parents work with the child while the therapist provides consultation and guidance.


Many children benefit from devices that enhance communication, such as learning signs, pictures or picture-exchange systems, and various types of talkers. These tools should be used as part of spontaneous communication and floor-time activities, for example, to help the child create a make-believe story or negotiate her needs.


A comprehensive program as described appears to require a great deal of time, energy, and, if the services are not covered by insurance or are not available through the school system, financial expenditure. Parents need to work collectively to make these services available through health-insurance and educational programs supported by the school system. There is a systematic tendency in health coverage and managed care to be biased against children with special needs. For example, certain therapies to correct hypotonia or severe, biologically based auditory-processing problems are often not covered by health-insurance plans or managed care, whereas other medical illnesses, such as congenital heart disease, are covered in most health-insurance plans.


In many communities, the educational system does not provide sufficient individual speech therapy or occupational therapy to remediate adequately the processing challenges of many children. In the long run, collective efforts by parents are needed to initiate change. In the meantime, parents can create and structure their own intervention team and, with appropriate knowledge, serve as its quarterback. The heart of the program, again, is the home-based Floortime component. Although it does require a lot of time and effort, this piece can be implemented with a relatively small financial expenditure if, for example, students are hired to help or, even better, volunteers, relatives, or extended-family members work with the child.


Families who are unable financially to provide intensive speech or occupational therapy and for whom services are not available may hire therapists on a consultant basis, perhaps considering speech and occupational therapists who work within the school system as consultants for a home-based program. In this way, in addition to the floor-time exercises, parents can undertake a certain amount of speech-therapy exercises and occupational-therapy exercises each day or every few days.


Even when optimal intensive services are available through the community or through independent arrangements, it is still incumbent on parents to develop an intensive, comprehensive program in which their child, for many hours a day, has an opportunity to practice his new skills and build strong foundations for further development.