The Developmental, Individual Difference, Relationship-based (DIR) Approach
By Lori Jeanne Peloquin, Ph.D
Casey, age 3 1/2, sits on the floor, pushing a truck back and forth, with no signs of enjoyment in what he is doing. His mom pushes a small car next to his but instead of looking up at her, he moves his truck a foot away and starts again. His mom pushes her car into his truck so they make a crashing noise. Casey picks up his truck and this time, moves across the room, turning his back on her. His mom finds a train and sets it down next to him. As he picks up the train, she takes the truck, until Casey reaches for it, and then she gives it right back, making a trade: first the train, then the truck, around in a circle, back and forth, back and forth.
Success! Casey is beginning to accept his mom as part of his play. However, this has taken months of work. Casey’s mom has gently, patiently, and persistently searched for a way to make interaction fun, looking for a change in his expression, the gleam in his eye that tells her a connection has been made. This is the process of Floor Time and wooing the child into interaction. Finding a way to make being with others pleasurable and interesting; following the child's lead; keeping the interaction going - this is the heart of the DIR approach.
Casey was identified as a child with an autism spectrum disorder when he was 2 1/2 years old. He was placed in a classroom for children with autism where he received speech and occupational therapies, but after a year had made very little progress, except to be able to follow the classroom routine with a picture schedule. He understood little spoken language. The only sound he made was a high pitched "eeee." He was usually expressionless, with few overt signs of joy or delight. He made very little eye contact, and usually avoided interaction. His parents feared he would never speak.
After changing to a new pediatrician, his parents were referred to a DIR-trained psychologist who coached them in a technique called Floor Time and organized a comprehensive DIR program. Within six months, Casey was attempting single words, and was signing frequently. He was finding joy in rough and tumble play and began to seek out people, even though it was difficult for him to keep the play going for more than a few minutes.
Now, after two years, Casey is speaking in two to five word phrases. He is very expressive and loves to play with others, sometimes for up to 45 minutes without stopping. He has learned to cue play partners about his wishes with eye-gaze, gestures, and words. He expresses his anger by stamping, or saying "mad", instead of screaming, and he follows verbal instructions with no visual cues. He imitates others well, likes to pretend, and includes feelings such as anger, fear, and nurturing into his play. He even spontaneously enticed the entire integrated preschool staff, parents and children to sing "Jingle Bells", by grabbing the microphone at a holiday party. His parents are astounded at his understanding of feelings and his ability to communicate.
What is the DIR Approach?
The Developmental, Individual Differences, Relationship-based Approach (DIR) is a comprehensive, interdisciplinary approach developed by Drs. Stanley Greenspan and Serena Wieder. It focuses on the total child, especially on his ability to interact with other people. The philosophy behind the method is that a child must be emotionally attached to the people in his world and have the ability to interact with them in order to develop cognitively and emotionally. Learning does not happen separately from emotional development, but together with it. Thus, the DIR approach starts with the things in which children are naturally interested and builds from there.
The child's difficulties in
interacting are viewed as primarily due to underlying
biologically-based sensory processing issues that affect the child's
ability to make sense of, and respond to, the world around him. As a
result, the child's relationships, learning, and interactions with
others can get derailed and the child begins to avoid the interpersonal
world. In the DIR approach, the first goal is to help the child work
around sensory processing difficulties to reestablish a meaningful
relationship with his parents. For example, for a child who is in his
own world and not relating to others, the first emphasis would be on
enticing him into the world by giving him a greater degree of pleasure
DIR takes into account the child's feelings, relationships with caregivers, developmental level and individual differences in his ability to process and respond to sensory information. It focuses on the child's skills in all developmental areas, including social-emotional functioning, communication, thinking and learning, motor skills, body awareness, and attention. It is less focused on specific academic skills, recognizing that those skills will develop more readily when he has a solid foundation from which to learn.
Principles of DIR
DIR is an individualized intervention that takes into account the uniqueness of every child and family. The principles of the model can be organized into three broad areas:
Developmental. How is the child developing emotionally, socially and cognitively? For example, does she engage with others, and does she initiate interaction with others? Can she use gestures to communicate? DIR looks at six stages that the child must master including:
For example, when he started treatment, Casey only showed a few skills at stages one and two. Casey now shows skills at all of the first five stages.
Individual Differences. Each child is unique. The specific biological challenges that a child shows will affect how she learns and relates to others. Understanding the particular pattern of challenges is crucial for helping her. For example, for a child with sensitivity to loud noises, we tailor our approach by engaging her with a lot of facial expression and big gestures, but speaking very quietly, if at all. We look for these individual differences across several areas, and guide our interactions with her accordingly. These areas include:
Because Casey showed difficulty processing auditory input, it was crucial to get in front of him, provide visual support through objects and toys, use many gestures and provide high affect cues through facial expressions and sound effects. His motor planning challenges required careful attention to his cues about what he wanted to happen, and to help him put an idea or desire into action.
child's developmental challenges and individual differences affect how
he can relate to others and affect the child's relationships. The
approach assists caregivers in developing their relationships with him,
so they can be effective in helping him to learn and grow. The child's
abilities to develop meaningful relationships with peers and siblings
are also important. Emotionally based interactions are at the heart of
One of the key intervention strategies utilized is Floortime, which involves getting down on the floor and actively playing with the child. Floortime basic principles include:
For example, a parent might do something with a child that she knows he will enjoy, like building a block tower and letting him knock it down. After 20 times, mom might see if the child would add one block to the tower the next time. If a child likes to throw toys, a parent might grab a basket and try to catch what he throws. The focus is always on maintaining a continuous flow of interaction, so that the child and parent feel connected and are communicating, rather than teaching specific skills or directing the child's play.
Floor-time is more than getting on the floor and playing, or simply following a child around doing whatever he wants. It is identifying the child as leader, then joining him and keeping the play interactive, with give and take. It is about facilitating communication and problem solving. DIR teaches the child about the value of communicating through facial expressions, non-verbal cues, and the use of gestures, then encourages the child to use these non-verbal cues to communicate with others, at least in part through careful attention to all of the cues the child gives.
When earlier developmental stages have been mastered and the child can maintain a continuous flow of interaction and engagement, Floor Time is focused on playing symbolically, so that the child learns to understand the full range of feelings and develops interpersonal problem solving. The intervention is also focused on helping the child begin to develop abstract thinking through making comparisons and judgments based on their own emotional experience.
The DIR approach incorporates the use of a wide range of services, usually including:
Levels of service are determined based on the specific needs of the child. In general, services are delivered at an intensive level to keep the child continually engaged with the environment. Most programs include three to five hours of intensive Floor Time interaction, provided in 20-30 minute sessions throughout the day (much of which will be provided by parents and other care-givers).
Younger children (0-3) generally receive most of their services at home. Older children usually attend some type of preschool, often where they can be integrated or included into the classroom with typically developing children. This is especially important because a child who falls within the autism spectrum needs to have children around him who will pull the child into interaction and who will be readily engaged themselves. Normally developing children also provide good role models for language development. There is a strong emphasis on the development of peer interaction and the inclusion of peer play as a regular part of treatment, depending on the child's functional developmental capacities.
The role of parents in DIR is crucial. They will often need to make significant changes in the way they interact with their child throughout the day, making a commitment to spend a considerable amount of time on the floor, playing with their child and becoming part of his world, even if his activities are limited. It involves responding to his every utterance or gesture, in an effort to spark a response, giving endless choices to close one more circle, or engaging in endless debates and negotiations to help him develop his ability to reason. For families such as Casey's, DIR becomes a way of life, one that is both demanding and exhilarating, as they help their child climb the developmental ladder, one rung at a time.
The DIR model is useful in
working with children at all points on the autistic spectrum. Some
children benefit considerably from the approach, making rapid progress.
Other children make slower progress, or with an uneven course. It is not
yet clear which children will benefit most from the approach. Some
children who seem very difficult to reach will make very rapid progress
once the treatment is started. In a review (Greenspan &Wieder, 1997)
of 200 children who received DIR treatment and were seen by Drs.
Greenspan and Wieder, 58% of children achieved excellent or good
outcomes. These children showed warmth and related to their environment
with joy and pleasure. They were able to use ideas creatively, engage in
spontaneous back & forth conversation, and answer questions
(including "why" questions). They showed less self-absorption and
repetitive behaviors. A group of 20 children who had made especially
good progress were found to be no different from a group of 20 typically
developing peers on their functional developmental emotional
capacities. They were rated by trained clinicians who had no knowledge
of the child's diagnosis.
The DIR approach is most effective when all therapies are provided using DIR principles, and care is coordinated by a DIR clinician. Professionals may need to seek additional training or consultation in the model. There are rapidly growing numbers of trained clinicians that provide DIR-based services and the frequent coaching and support that parents need. Additionally, many parents start DIR support groups, attend conferences, & train themselves and their teams, by reading The Child with Special Needs: Encouraging Intellectual and Emotional Growth.