Guidelines for a DIR® Program

 Guidelines for a Comprehensive DIR® Program

For individuals who have challenges in relating and communicating, often diagnosed with autism or another 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 person (often a child).  The assessment needs to look beyond simply symptoms and diagnosis.  The assessment needs to look at the whole person and all of their individual differences. Human developmental challenges cannot be addressed adequately by focusing simply on one or two life domains or aspects of development.  The assessment and subsequent treatment, service, and/or education plans need to look at the whole individual from a transdisciplinary lens.  

A DIR Program is not limited to just DIRFloortime (aka 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, transdisciplinary DIR-based manner that supports the overall development of the individual.  While there can be behavioral management techniques utilized to help maintain safety and help with simple behavioral modifications, systematic behavioral approaches such as Applied Behavioral Analysis (ABA) should not be a part of a comprehensive DIR program.  These behavioral approaches can work against the efforts of therapy and can undermine the developmental process a DIR program is working to mobilize.  

While a comprehensive DIR Program comprises many elements, the cornerstone is the DIRFloortime home program. DIRFloortime at home is ideally provided by parents and other natural and informal supports .  The secured attached relationships such as parents, grandparents, aunts and uncles, and even siblings can be particularly effective because of the unique, enduring, and powerful nature of these relationships.  Other supports such as a close friend of the parent, a member of shared religious community, a coach, or many other informal supports can be ushered by the parents to be a part of the DIRFloortime home program as well.  In some situations, it may be prudent to supplement the DIRFloortime provided in the home by parents and natural or informal supports with professionals and/or paraprofessionals, but this should only be done to supplement, not supplant, the role of the secured attached relationships in the home.  

The current guidance from ICDL, based on research findings from DIRFloortime studies and studies on intensity of therapy for autistic children more broadly, is to have approximately 12 hours a week of DIRFloortime interactions at home with the family and other natural and informal supports.  These 12 hours can be reached by having both structured DIRFloortime "sessions' of about 20 minutes at a time and/or integrating DIRFloortime processes into everyday activities.  Even though 12 hours can seem like quite a bit of time, the integration of DIRFloortime processes into everyday activities makes getting to a total of 12 hours very reasonable for most families.  

There are many hours in the day. If the child spends too large a portion of their day involved in self-absorbed activities, self-stimulation, or on screens which only provide one-way communication, they may not have the practice the need to develop core developmental capacities or learn essential skills. A child's developmental progress is generally proportional to the amount of energy and time spent in engaging interactions with others. Being mindful of how much time a child spends in activities such as interacting with screens is important for all children. Engaging and interactive time with other people is really good for human development and learning as well as a person's overall mental and physical health.  This is a particularly important consideration for children with developmental differences and/or challenges.  

Children with developmental challenges, in order to learn to relate, communicate, and think and reason, 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 (in whatever way they communicate), 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 two 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 developmental challenges 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 not-yet-speaking three-year-old, perhaps helping them move their truck or doll or hiding with them in the hide-and-seek game. When the not-yet-speaking 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 DIRFloortime 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 and language therapist to help with receptive and expressive language. An optimal program may involve speech therapy in individual sessions one-half to one hour long two or more times per week. An occupational therapist trained in sensory integration may be needed to work on sensory modulation, sensory processing, posture, motor planning, and other related needs 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 DIRFloortime.

Finally, many children benefit from being in an educational program.  The optimal educational program, in addition to providing services for children with developmental and learning differences, also provides access to other children who are very interactive and have spontaneous communicative skills. Thus as the child 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 developmental and learning differences to interact with children who may be more typically developing or who have medical or learning problems that do not limit communication and interaction are very important.

It is important to have a DIR coach (DIR-Advanced or DIR-Expert level professional) that provides coaching to families on how to facilitate DIRFloortime interactions in the home and community. This DIRFloortime coach can work closely with the parent(s) and/or caregivers to help them learn how to create the necessary DIRFloortime interactions. It may be beneficial for the DIR-coach and/or a developmentally based DIRFloortime practitioner under the supervision of the DIR coach, to work directly with the child one to four times a week, in addition to the coaching. With some families, these two pieces are integrated; the DIRFloortime coach  works directly with the child while the parents are there, and then the parents work with the child while the coach provides consultation and coaching.

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

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 DIRFloortime component. Although it does require time and effort, this piece can be implemented with a relatively small financial expenditure and research has shown that it does not increase parental stress.  If anything, the stress parents report decreases.  When parents learn how to help their children thrive, especially when they have developmental differences such as autism, parents feel empowered not stressed.   

ICDL offers DIR Intensives at our DIR Institute that can help families "jump start" a DIR home program.  There are also many providers around the world that have similar programs.  This can be a great way to get a DIR home program started off quickly and effectively.  

To learn more about ICDL's Clinical Practice Guidelines, please click here.