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DIR/ Floortime



What is DIR/ Floortime?
The Developmental, Individual-Difference, Relationship-Based model (DIR®) and Floortime Model were developed by Dr. Stanley Greenspan.1 The objectives of the DIR/Floortime Model “are to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviors.”2 Although Floortime is at the heart of this model, the intervention program also involves “different therapies like speech therapy, occupational therapy, physical therapy, education programs, counseling supports for parents, and intensive homes programs as well as school programs.”3 The Developmental, Individual-Difference, Relationship-Based model is a developmental program that “focuses on constructing an assessment and treatment program that works with all facets of the child’s disorder and identifies and intervenes with the child and family’s unique pattern.”4 According to Dr. Greenspan,3 Floortime is best thought of in two ways:


  • A specific technique where for 20 or more minutes a parent gets down on floor to interact with their child
  • A general philosophy that characterizes all the interactions with the child, because all interactions have to incorporate the features of Floortime as well as the particular goals of that interaction, be it speech therapy or occupational therapy or a special set of educational goals

Interactive play is an integral part of any child’s development and a major component of the DIR/Floortime Model. By implementing play, a parent or instructor “uniquely addresses the core deficits of relating and communicating as no other approach can. Interaction is the key to facilitating development, where long sequences of back and forth co-regulated affect cues help the child focus, initiate and elaborate ideas.”5 Affect cues, such as actions facial expressions and tone of voice, help give meaning to words, actions, and the use of figures and toys. The DIR/Floortime model has defined six developmental milestones that are important to achieve emotional and intellectual growth. A 2003 article in the journal Autism5 defines these six developmental milestones as:

  • Stage 1: Self-Regulation and Shared Attention (Interest in the World)- Draw the child’s attention with enjoyable interactions that involve looking, hearing, touching, and movement
  • Stage 2: Engagement and Relating - emphasize relationships all the time to develop a sense of security, intimacy, caring, and empathy
  • Stage 3: Two-Way Communication – Follow the child’s lead and use affect cues to woo and wait for the child’s purposeful social gestures to express desires, objections, or other feelings. Get reciprocity by challenging the child to do things to you, help them achieve their goal, and later build obstacles to add steps.
  • Stage 4: Purposeful Complex Problem Solving Communication- Work up to a continuous flow of 30+ back and forth circles of communication. For example, the child can take the parent by the hand, walk to the door, point that he/she wants to go out, perhaps use a sound or word so the parent further understands his/her intention. Expand the conversation by asking short questions, like “Where do you want to go?” “What do you need?” These conversations negotiate the most important emotional needs in life, such as being close to others, exploring and being assertive, limiting aggression, etc.
  • Stage 5: Creating and Elaborating Symbols (Ideas) – Encourage the child to relate sensations, gestures, and behaviors to the world of ideas. Engage in long conversations to communicate interests, feelings, desires, and objections throughout the day.
  • Stage 6: Building Bridge between Symbols (Ideas) – Challenge the child to connect his/her ideas together by seeking his/her opinion, enjoying his/her debates, and negotiating for things he wants using logical reasons. This capacity is essential for separating reality from fantasy, modulating impulses and mood, and learning how to concentrate and plan.

These six milestones form a “symbolic developmental ladder” as each milestone “layers new abilities onto those of prior stages…each one marks a major turning point in the life of a child.”6


How does the DIR/ Floortime Model make a Difference for Children on the Autism Spectrum?
The DIR/Floortime Model “is a comprehensive framework which enables clinicians, parents, and educators to construct a program tailored to the child’s unique challenges and strengths.”2 The model stresses the importance of parents and family members in building emotional relationships with the child. Spontaneous communication and nurturing relationships are two basic components of the DIR/Floortime Model.7 During play sessions the adult will follow the child’s lead, which according to Dr. Greenspan “will encourage the child to ‘want’ to relate to the outside world.”1 Being creative and spontaneous and expanding the action and interaction to include all of the child’s senses, motor skills, and a range of emotions can help the child “practice basic thinking skills: engagement, interaction, symbolic thinking and logical thinking.”12



What do DIR/ Floortime Treatment Providers Do?
According to the Interdisciplinary Council on Developmental and Learning Disorders (ICDL),2 the typical DIR Model intervention includes:

  • Home-based developmentally appropriate interactions and practices, including:

-Floortime sessions: Encourage the child to demonstrate initiative and purposeful behavior, deepening engagement, lengthening mutual attention, and developing symbolic capacities through pretend play and conversation, all of which follow the child’s lead.


-Semi-structured problem solving: These challenges can be set up as selected, meaningful, and relevant learning activities that, when solved, teach the child something new.


-Motor, sensory, sensory integration, visual spatial, and perceptual motor activities: These activities are tailored to each child uniquely. The activities work to build basic processing capacities and provide the support to help children to become engaged, and attentive during interactions with others.


-Peer play with another child: The instructor should allow peer play only when the child is fully engaged and interactive and should only intervene when it is necessary to encourage engagement and interaction between the children.


  • Individual Therapies:

-Speech, language, and oral motor therapies


-Sensory motor and sensory integration based occupational therapy and/or physical therapy


-Other therapies as required


  • Educational Program:

-For children who can interact and imitate gestures: Integrated, inclusive program or regular school program with additional teacher or aide if needed


-For children not yet able to engage in preverbal program solving or imitation: Special education program with a strong focus on engagement and preverbal purposeful gestural interaction


-Transitional educational-type programs with typical peers


  • Other interventions (when necessary):

-Biomedical interventions


-Nutrition and diet


-Technologies



A professional can teach the Floortime method to parents for home-implementation. Floortime sessions usually consist of 20 minute or more sessions conducted throughout the day. According to Dr. Greenspan and Dr. Serena Wieder,7 co-founder of the ICDL and colleague of Dr. Greenspan, the highlights of a comprehensive schedule for the DIR/Floortime Model can look similar to the following:

  • Six daily Floortime sessions
  • Four semi-structured and sensory-motor activities
  • Intensive speech and occupational therapies,
  • 3-5 play dates weekly
  • Inclusion in a preschool setting
  • Various music, gym, drama, and sports activities

What can you expect from a DIR/ Floortime treatment provider?
Before developing an intervention program, a certified DIR/Floortime clinician will conduct a “comprehensive functional development evaluation [which] involves all the relevant functional areas, including a child’s individual processing differences, functional development level, child-caregiver interactions, family functioning.”8 Some of the areas assessed in the Functional Developmental Evaluation include motor and perceptual-functioning, developmental history, biomedical evaluation, auditory processing, and functional language skills.9


An intervention program is developed based on this clinical assessment that can be implemented throughout the child’s day in preschool, at home, during play dates, and by professionals. An overview of how to get started implementing the DIR/Floortime Model into home, preschool, and professional environments can be found on the Interdisciplinary Council on Developmental and Learning Disorders website.


Who is Qualified as a DIR/ Floortime Provider?
The Greenspan Floortime Approach offers courses and workshops for both parents and professionals interested in applying the DIR/Floortime approach. These courses and workshops vary from 6 to 16 hours, but the longer courses are tailored specifically to professionals.10



The ICDL website provides information about their Training Program that details the course curriculum and the steps necessary to become a certified and eligible for placement in their DIR/Floortime Community Directory. Professionals are able to become certified at distinct levels from beginner to expert.


What Research is there to Support the DIR/ Floortime Model?
In 2015, The National Standards Project released Phase 2 of their report detailing the efficacy of various autism-related interventions. The report categorized the DIR/Floortime Model as an “unestablished treatment.”11 According to their report, an un-established treatment indicates “there is little or no evidence to allow us to draw firm conclusions about interventions effectiveness with individuals with ASD. Additional research may show the intervention to be effective, ineffective, or harmful.” 11 The DIR/Floortime Model has been described by the Centers for Disease Control and Prevention (CDC) and Autism Speaks as “one of the most common interventions for children with ASD.”7 In 2011, two studies that were conducted in Canada and Thailand found additional evidence to support the use of the DIR/Floortime model for children with autism spectrum disorders. A small pilot study in Taiwan, which involved only 11 children with ASD, found that after a 10-week home-based intervention program “children made significant changes in mean scores for emotional functioning, communication, and daily living skills.” http://www.ncbi.nlm....pubmed/24865120. However, this these results must be repeated on a larger scale before this treatment is deemed an effective intervention for autism. According to Research Autism, “there is limited research evidence on the use of the DIR method (Floortime) as a treatment for autistic children.”


How can I find a DIR/ Floortime Provider?
The Interdisciplinary Council on Developmental and Learning Disorders (ICDL) provides a U.S. and International directory for DIR/Floortime providers that can be found listed under DIR®Floortime™ Communities. Each provider within the directory is listed according to his/her certified level of achievement.



References