NEWEST RANDOMIZED CONTROLLED TRIAL: SEALY, J. and GLOVINSKY, I. P. (2016), STRENGTHENING THE REFLECTIVE FUNCTIONING CAPACITIES OF PARENTS WHO HAVE A CHILD WITH A NEURODEVELOPMENTAL DISABILITY THROUGH A BRIEF, RELATIONSHIP-FOCUSED INTERVENTION. Infant Ment. Health J.. doi: 10.1002/imhj.21557
Four randomized-controlled studies were published since 2011 identifying statistically significant improvement in children with autism who used Floortime (Sealy & Glovinsky, 2016; Solomon, et. al., 2014; Casenheiser, Shanker & Steiben, 2011; Lal and Chhabria, 2013; Pajareya and Kopmaneejumruslers, 2011). These studies also showed the effectiveness of addressing the caregiver (Solomon, et. al., 2014; Casenheiser et. al., 2011) and specific skill improvement including turn taking, two way communication, understanding cause and effect and emotional thinking (Lal and Chhabria, 2013).
Solomon, Necheles, Ferch, and Bruckman (2007) conducted a pre-post survey of the Play and Language for Autistic Younsters (PLAY) Project Home Consultation program. This program, based on the DIR model, is used in fifty agencies across seventeen U.S. states. Results indicated statistically significant improvement in the children’s Functional Developmental Levels and 100% of the parents reported satisfaction in participating.
In 2002, a pre/post-randomized controlled trial utilizing an approach based on developmental, individual-differences, and relationship-based philosophy was published by Salt, Shemilt, Sellars, Boyd, Coulson and Mc Cool. The study showed not only statistically significant improvement in specific skill development, but also that caregivers reported a decrease in stress with treatment while the control group showed an increase in stress.
Case studies have also been effective in supporting the use of DIRFloortime with children with autism. Dionne and Martini (2011) demonstrated statistically significant improvement in communication between parent and child. Wieder and Greenspan (1997, 2005) did comprehensive case studied that spanned from 8-15 years. These studies supported the long lasting results DIRFloortime had on individual child skills, as well as, the emotional connections the families were able to develop over time using this approach.
Floortime and related DIR based approaches are listed on
evidence-based treatment reviews. Most
recently, the Journal of Clinical Child and Adolescent Psychology published an
article entitled, "Evidenced Base Update for Autism Spectrum Disorder" where they categorized Floortime as a "Developmental Social
Pragmatic (DSP) Parent Training" and listed focused DSP Parent Training in
their second level evidence base category indicating it as "Probably
Efficacious." (Smith & Iadarola, 2015) Several recent studies on Floortime were cited in the
article including the recent randomized clinical trial studies. The research is
beginning to catch up with what we have known in practice for many years.
Establishing the evidence-base behind DIR and DIRFloortime/Floortime is not as easy as in some approaches. DIR is an interdisciplinary, individualized, whole-child, developmental approach that is broad in both its approach and its impact. Unlike behavioral approaches that can simply show that a specific behavior that has been targeted to increase or decrease has changed, DIR is focused on improving the whole child in a wide range of ways. Nevertheless, the research continues to build to support DIR and the DIRFloortime approach.
Recent Research: The Evidence to Support DIRFloortime® Continues to Build
These recent studies bring more evidence of how effective, and culturally appropriate, DIRFloortime is in helping children and families around the world:Casenhiser D.M., Shanker, S., Stieben J. Learning Through Interaction in Children with Autism: Preliminary Data from a Social-Communication-Based Intervention. Autism, published online September 26, 2011.
Solomon, R., Van Egeren, L., Mahoney, G., Quon Huber, M., Zimmerman, P. (2014). PLAY Project Home Consultation Intervention Program for
Young Children With Autism Spectrum Disorders: A Randomized Controlled Trial. Journal of Developmental and Behavioral Pediatrics, 35(8),
Pajareya K, Kopmaneejumruslers K. A pilot randomized controlled trial of DIR/Floortime parent training intervention for pre-school children with autistic spectrum disorders. Autism, published online before print, June 13, 2011.
Dionne M, Martini R. Floor Time play with a child with autism: A single-subject study. Revue canadienne d'ergotherapie, juin 2011, 78(3)
Casenhiser DM, Binns A, McGill F, Morderer O, Shanker SG. (2015). Measuring and supportinglanguage function for children with autism: evidence from a randomized controltrial of a social-interaction-based therapy. Journal of Autism and Developmental Disorders, 2015 Mar; 45(3):846-57
Sealy, J. and Glovinsky, I. P. (2016), Strengthening the Reflective Functioning Capacitiesof Parents Who have a Child with a Neurodevelopmental Disability through a Brief,Relationship-Focused Intervention. Infant Mental Health Journal. Doi: 10.1002/imhj.21557.
Christian, G (2011). A Person-Centered Approach to Problem Behavior: Using DIR®/Floortime with Adults Who Have Severe Developmental Delays. The NADD Bulletin, 2011, March/April, 14(2), 21-31.
Mok, J.W.S. and Chung, K.H. (2014). Application ofDIR/Floortime Model in the Psychiatric Service for Very Young Children with Autism in Hong Kong. Hong Kong Journal of Mental Health. 2014, 40(1), 23-30.
Read research on the DIR based assessment tools:
Functional Emotional Assessment Scale (FEAS)
Greenspan Social-Emotional Growth Chart
Functional Emotional Assessment Scale
The Functional Emotional Assessment Scale by Stanley Greenspan, Georgia DeGangi, & Serena Wieder enables clinicians, educators, and researchers to observe and measure emotional and social functioning in infants, young children, and their families. Historically, the complexity of emotional functioning has been difficult to measure and assess. The FEAS meets this longstanding need of the field. The FEAS conceptualizes, operationalizes, and measures in a reliable and valid manner:
Download the Book and Score Sheets (free):
DIR Related Research
Gernsbacher M.A., (2006). Toward a behavior of reciprocity. Journal of Developmental Processes, 1, 139-152. http://psych.wisc.edu/lang/pdf/gernsbacher_reciprocity.pdf
Gernsbacher has shown that intervention can change the way parents interact to increase reciprocity and that these changes are correlated with changes in social engagement and in language.
Kasari et al. 2008 used a randomized, controlled trial looking at joint attention and symbolic play in 58
children with autism. Results indicate that expressive language gains were greater for treatment groups that used developmental approaches compared with the control group that was based only on behavioral principles.
Kasari, Connie; Paparella, Tanya; Freeman, Stephanny; Jahromi, Laudan B. “Language outcome in autism: Randomized comparison of joint attention and play interventions.” Journal of Consulting and Clinical Psychology. Vol. 76(1), Feb 2008, 125-137.
Affleck, G., et al. (2001). Promise of relationship-focused early intervention in developmental disabilities. Journal of Special Education, 16, 413-430.
Dominguez, G. Dominguez, J., Stieben, J.
& Shanker, S. (2013), The Imaginary part of
coherency in autism: Differences in cortical functional connectivity in
preschool children, PLOS ONE.
Kim, J. and Mahoney, G. (2005). The effects of relationship focused intervention on Korean parents and their young children with disabilities. Research in Developmental Disabilities, 26, 117-130.
Mahoney, G. & Perales, F. (2003). Using relationship-focused intervention to enhance the social-emotional functioning of young children with autism spectrum disorders. Topics in Early Childhood Special Education, 23, 74-86.
Mahoney, G., and F. Perales. (2004). “Relationship-focused early intervention with children with pervasive developmental disorders and other disabilities: a comparative study.” Journal of Developmental & Behavioral Pediatrics 26, 77-85.
Shanker, S (2012) Calm Alert and Learning: Classroom Strategies for Self-Regulation. New York: Pearson.
Shanker, S (2013) Emotion regulation through the ages. In T. Racine & A. Foolen (eds.), Moving Ourselves.
Shanker, S and J Stieben (2009), ‘The Roots of Mindblindness’, in Ivan Leudar (ed.), Against Theory of Mind. London, Palgrave Macmillan.
Shanker, S & Casenhiser, D (2013), Reducing the Effort in Effortful Control. In The Role and use of Conceptual Analysis in Psychology, T. Racine & K Slaney (Eds.). Palgrave.
Dr. Nancy Minishew presented neurological findings
regarding the differences in persons with and without autism, and suggested
that affect-based interventions are critical to address the underlying
neurological core deficits in autism.
Minishew, N.J and Williams, D.L. (2008) Brain behavior connections in autism. In K.D. Buron and P. Wolfberg (Eds.), Educating learners on the autism spectrum: Translating theory into meaningful practice. Shawnee, KS: Autism Asperger Publishing Co.
Casenhiser, D , Shanker, S and Stieben, J. (2011) Learning through interaction in children with autism: Preliminary data from a social-communication-based intervention Autism: The international journal of research and practice., 1-22. This ongoing research study by Casenhiser, Stieben and Shanker at the Milton and Ethel Harris Research Institute at York University is investigating behavioral and neurophysiological outcomes of intensive social-affect-relationship-based intervention known as MEHRIT, using both ERP and EEG measurements. A preliminary report of a randomized controlled trial with results of the first year of a two-year intervention shows significant effectiveness of the ‘social-communication approach’ based upon this framework. They have found significant improvements in social interaction skills after 2 hours/week of DIR-based therapy for one year. Two studies of the results of imaging studies have now been submitted for publication:
·Sigman, M., Siller, M. (2003). The Origin of Language: Evidence from Longitudinal Research in Autism. Journal of Developmental and Learning Disorders, 7 1-14.
Williams, D.I. (2008). What neuroscience has taught us about autism. Zero to Three. 11-17
Center on the Developing Child at Harvard University (2011). Building the Brain’s “Air Traffic Control” System: How Early Experiences Shape the development of Executive Function: Working Paper No. 11. http://wwwdevelopingchild.harvard.edu. “Children with special needs, such as those associated with autism…may have particular difficulty with executive functioning demands” P. 6.
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 Diagnoses by Stanley I. Greenspan, M.D., & Serena Wieder, Ph.D.
Charts of 200 children who were diagnosed with autistic spectrum disorder were reviewed. The 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 chart review suggests that a number of children with autistic spectrum diagnoses are, with an appropriate intervention program, capable of empathy, affective reciprocity, creative thinking, and healthy peer relationships; that an intervention approach that focuses on individual differences, developmental level, and affective interaction may be especially promising; and that there are different underlying processing patterns with a difficulty in connecting affect and sequencing capacities as a possible common denominator. It also suggests that there is an early marker, the difficulty in engaging in complex purposeful gestural communication, and that contrary to traditional beliefs, a significant number of children may have relatively better functioning in the first year with a regression in the second and third years. This review also suggest that difficulties with relating and intimacy are often secondary to underlying processing disturbances. Many children can become quite loving and caring, thoughtful, and creative, suggesting a need to change the criteria for diagnosing these disorders.
To read the complete article please click here.
The Bridge Project 2009 is a joint effort of the Bridge Collaborative, a group comprised of UCSD, Rady Children's Hospital, the San Diego Regional Center, the Harbor Regional Center (Torrance, Long Beach), Kaiser Permanente, parents, and private providers, and others. They were awarded a $250,000 NIH R01 grant for a pilot study, with a clear path toward a $2,500,000 grant, to implement evidenced based screening and intervention in Southern California. They have chosen Project ImPACT and added components of engagement, individual differences, and reflective process
More Research, Articles, and Reports
The P.L.A.Y. Project Awarded $1.85 Million Grant from the National Institute of Mental Health Grant to Fund Research on Play-based Early Intervention for Autism; Confront Increasing Numbers of Young Children on the Spectrum
Ann Arbor, Mich.—September 24, 2009—Through the support of a $1.85 million grant from the National Institute of Mental Health (NIMH), Richard Solomon, MD, is conducting a three-year study of The Play and Language for Autistic Youngsters (P.L.A.Y.) Project Home Consulting model, a parent-training program that addresses the need for intensive early intervention for young children on the autism spectrum. Developed by Dr. Solomon, P.L.A.Y. is a practical, family-friendly application of renowned child psychiatrist Dr. Stanley Greenspan’s Developmental, Individual-differences, Relationship-based (DIR) framework, popularly known as DIR/Floortime. 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.
Final research results released in October 2014. Read the full article by clicking here.
DIR/Floortime and Autism Spectrum
Disorders: Overview and Summary of
Scientific and Public Support
(An older 2010 overview, but some good information and links still...)
The Developmental, Individual Difference, Relationship-based (DIR/Floortime) Model is a developmental, interdisciplinary framework that enables clinicians, parents and educators to construct a comprehensive assessment and intervention program based on the child’s and family’s unique developmental profile. It enables the individual working with the child to enter the child’s world, bring the child into a shared world, and, from there, interact with the child in ways that build the foundations for social, emotional, and intellectual development. The profile includes understanding the child’s emotional, social, and intellectual level; individual differences in motor, sensory, and language functioning; and the existing caregiver, child and family functioning and interaction patterns.
on years of research in developmental
psychology that underscores the importance
of early relationships and family
functioning, the DIR/Floortime Model also
integrates research contributions from
various disciplines, such as speech and
language pathology occupational therapy
social work, and marriage and family
therapy. Neuroscience research lends
further support to developmental
interventions. Early relationships and
reciprocal interactions between infants
and caregivers appear vital for the
creation of healthy brain development,
including for example wiring the
pre-frontal cortex. These diverse
contributions provide a rich structure so
that clinicians can understand the child
and family’s unique profile. This
understanding is crucial for implementing
a comprehensive assessment and
intervention program for children with
autism spectrum disorder (ASD) as well as
related special needs conditions.
Guidelines for Early Identification, Screening, and Clinical Management of Children With Autism Spectrum Disorders by Stanley I. Greenspan, MD, T. Berry Brazelton, MD, José Cordero, MD, MPH, Richard Solomon, MD, MPH, FAAP, Margaret L. Bauman, MD, FAANP, Ricki Robinson, MD, MPH, FAAP, Stuart Shanker, DPhil and Cecilia Breinbauer, MD, MPH
Congratulations to the American Academy of Pediatrics (AAP). Two of their recent clinical reports published in Pediatrics, "Identification and Evaluation of Children With Autism Spectrum Disorders"1 and "Management of Children With Autism Spectrum Disorders,"2 will enable pediatricians to address parent concerns sooner, facilitating the early identification of children with autism spectrum disorders (ASDs). As physicians and developmentalists with decades of accumulated experience in working with children with developmental challenges, we applaud and welcome these publications. However, we would like to expand on these reports. In this commentary we (1) describe a broader functional/developmental framework for screening for ASDs, (2) provide a critique of the current trend toward behavioral treatments as primary intervention strategies, and (3) present research evidence for functional/developmental approaches.
To read the complete article please click here (please be aware that you must click the link titled "Full Text PDF" to the right of the page to access full article)
Pilot Study of a Parent Training Program for Young Children
with Autism. The PLAY Project Home Consultation Program by Richard Solomon, Jonathan Nechels,
Courtney Ferch &
David Bruckman Autism © 2007 SAGE Publications and The National Autistic Society Vol 11(3) 205–224
Sixty-eight children completed the 8–12 month program. Parents were encouraged to deliver 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. There were no significant differences between parents in the FEAS subscale scores at either preor post intervention and all parents scored at levels suggesting they would be effective in working with their children. Overall satisfaction with PPHC was 90 percent. Average cost of intervention was $2500/year. Despite important limitations, this pilot study of The PLAY Project Home Consulting model suggests that the model has potential to be a cost-effective intervention for young children with autism.
To read the complete article please click here.
Academy of Sciences Report: Excerpts from Engaging Autism
Using the Floortime Approach to Help
Children Relate, Communicate, and Think
by Stanley I. Greenspan, M.D., Serena
Wieder, Ph.D. A Merloyd Lawrence Book Da
Capo Lifelong Books A Member of the
Perseus Books Group
To read the rest complete article please click here.
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
A follow-up study of 16 children diagnosed with an autistic spectrum disorder (ASD) revealed that with the DIR/Floortime approach, 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 with a family-oriented approach that focuses on the building blocks of relating, communicating, and thinking.
To read the complete article please click here
Relationship Focused Early Intervention With Children With Pervasive Developmental Disorders and Other Disabilities: A Comparative Study By Gerald Mahoney, Ph.D & Frida Perales, M.Ed.
This study compares the effects of relationship-focused early intervention on toddlers and preschool-age children who were classified as having either pervasive developmental disorders (PDDs) (N = 20) or developmental disabilities (DDs) (N = 30). The intervention was conducted over a 1-year period through weekly individual parent-child sessions. It focused on helping parents use responsive teaching strategies to encourage their children to acquire and use pivotal developmental behaviors that addressed their individualized developmental needs. Before and after comparisons indicated significant increases in parents’ responsiveness and children’s pivotal behavior. Both groups of children made significant improvements in their cognitive, communication, and socioemotional functioning. However, 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. J Dev Behav Pediatr 26:77–85, 2005. Index terms: early intervention, pervasive developmental disorders, relationship focused intervention.
To read the complete article please click here.
Recent Relevant Evidence-Base Practice Reviews
Tristram Smith & Suzannah Iadarola (2015) Evidence Base Update for Autism Spectrum Disorder, Journal of Clinical Child & Adolescent Psychology, 44:6, 897-922
Research on Social Work Practice indicating DIRFloortime as an Evidence-Based Practice (EBP)
Effect of Transdisciplinary Approach in Group Therapy to Develop Social Skills for Children with Autism Spectrum Disorder
(When you request access, please provide a detailed reason for your request. Thank you.)
Diagnostic Manual for Infancy and Early Childhood (ICDL-DMIC) URL
Clinical Practice Guidelines
CDC/ICDL Collaboration Report on a Framework for Early Identification and Preventive Intervention of Emotional and Developmental Challenges URL
DIR Reader (document password: dir1315)
Journal of Developmental Processes
Journal of Developmental and Learning Disorders