Guidelines for a DIR® Program
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 Floortime home program. The Floortime at home is 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 Floortime home program as well.
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 one-way communication, such as watching TV, they may not have the practice the need to develop and 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 engaging them into Floortime interactions.
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, 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 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 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 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.
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 Floortime therapist to work directly with the child one to four times a week, in addition to consulting and observing different family members engaged in Floortime interactions. With some families, these two pieces are integrated; the Floortime 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 communication devices. These tools should be used as part of spontaneous communication and Floortime 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 Floortime component. Although it does require a lot of time and effort, this piece can be implemented with a relatively small financial expenditure.
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 their new skills and build strong foundations for further development.