Research Supporting DIR/Floortime and relationship-based

models

September, 2010
Susan Gurry, Cambridge Public Schools
segurry@comcast.net
gurryconsulting@comcast.net

Introduction: Developmental models differ from behavioral

models in what to measure to account for change and growth.
Developmental models target underlying ‘capacities’, based
on a rich heritage of child development literature Bowlby,
1951; 1988; Ainsworth, 1967, 1978; Mundy, Sigman & Kasari,
1990; Mahoney & Perales, 2003; Gernsbacher, 2006) rather
than specific target behavior. Developmental models seek to
measure an individual’s capacity for:

• shared attention
• ability to form warm, intimate and trusting
relationships
• ability to initiate (rather than respond) using
intentful actions and social engagement
• ability to participate in reciprocal (two-way, mutual)
interactions while in a range of emotional states
• problem-solving through a process of co-regulation,
reading, responding and adapting to the feelings of
others
• thinking logically about the motivations and
perspectives of others
• developing an internal set of personal values.

Aldred, C., Green, J., & Adams, C. (2004, Nov.) A new social
communication intervention for children with autism: pilot
randomized controlled treatment study suggesting
effectiveness. Journal of Child Psychology and Psychiatry
(8):1420-30.

Randomized controlled trial (RCT) studies in the

psychosocial area have been rare but are essential because
of the developmental heterogeneity of the disorder. The
authors aimed to test a new theoretically based social
communication intervention targeting parental communication
in a randomized design against routine care alone. The
intervention was given in addition to existing care and
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involved regular monthly therapist contact for 6 months
with a further 6 months of 2-monthly consolidation
sessions. It aimed to educate parents and train them in
adapted communication tailored to their child's individual
competencies. Twenty-eight children with autism were
randomized between this treatment and routine care alone,
stratified for age and baseline severity. Outcome was
measured at 12 months from commencement of intervention,
using standardized instruments. All cases studied met full
Autism Diagnostic Interview (ADI) criteria for classical
autism. Treatment and controls had similar routine care
during the study period and there were no study dropouts
after treatment had started. The active treatment group
showed significant improvement compared with controls on
the primary outcome measure--Autism Diagnostic Observation
Schedule (ADOS) total score, particularly in reciprocal
social interaction--and on secondary measures of expressive
language, communicative initiation and parent-child
interaction. Suggestive but non-significant results were
found in Vineland Adaptive Behaviour Scales (Communication
Sub-domain) and ADOS stereotyped and restricted behaviour
domain.

Casenhiser (2000). Learning through interaction. Presented

at the ICDL Conference, Nov 8 & 9 2009.

Casenhiser states that changing behavior is not the same as

changing development. This is a study of two groups of
children, ages 2 to 4 yrs 11 months at time of enrollment;
their diagnosis of autism was confirmed by the ADOS or ADI.
Children receiving more than 15 hours of any other therapy
were excluded. The control group was composed of children
receiving preschool no other therapy an average of 3.9
hours/week. The DIR group received two hours a week of DIR
with interactions that were play based, topic of
interaction is child-centered. There were 56 participants
who completed 12 months of therapy, had both pre and post
assessment by assessors who were blind to group assignment
and who were unknown to the children. They reported results
that were clinically significant or near clinically
significant in the following areas:

*Attention to activity, joint attention, enjoyment in

interaction, involvement, language scores.

Greenspan, S.I. & Wieder, S. (1997). Developmental

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patterns and outcomes in infants and children with
disorders in relating and communicating: A chart review of
200 cases of children with autism spectrum diagnoses.
Journal of Developmental and Learning Disorders, 1, 87-141.
Charts of 200 Children who were diagnosed with autistic
spectrum disorder were reviewed. The goal of the review was
to reveal presenting patterns in presenting symptoms,
underlying processing difficulties, and response to
intervention in order to generate hypotheses for future
studies. The chart review suggests that 58% of children on
the spectrum were, with an appropriate intervention
program, capable of empathy, affective reciprocity,
creative thinking and healthy peer relationships. The
intervention was focused on individual differences,
developmental level, and affective interaction. This review
also suggests that difficulties with relating and
communicating may be secondary to processing disturbances.

Ingersoll, B., Dvortcsak, A., Whalen, C. & Sikora, D.

(2005) The effects of a developmental intervention on rate
of expressive language production in young children with
autistic spectrum disorders. Focus on Autism and Other
Developmental Disabilities, 20(4): 213-222.

Developmental, social-pragmatic interventions are based on

the study of interactions between typically developing
infants and their mothers. This study used a single-
subject, multiple-baseline design to examine the
effectiveness of a DSP language intervention on three
children with ASD. The results indicated that the children
exhibited increases in their use of spontaneous speech with
the therapists and their parents, who had not been trained
in this method.

Kasari, C., Gulsrud, A., Wong, C., Kwon, S., & Locke, J.
(2010) Randomized controlled caregiver mediated joint
engagement intervention for toddlers. Journal of Autism and
Developmental Disorders, 40 (9), 1045-1056

This study aimed to determine if a joint attention

intervention would result in greater joint attention
between caregivers and toddlers with autism. The
intervention consisted of 24 caregiver-mediated sessions
with follow-up 1 year later. The Immediate Treatment (IT)
group made significant improvement in targeted areas of
joint engagement. The IT group made significant
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improvements with medium to large effect sizes in their
responsiveness to joint attention and their diversity of
functional play acts after the intervention with
maintenance of these skills 1 year post-intervention.

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

This study investigates the effectiveness of relationship-

focused intervention on the social and emotional well-being
of children with autism spectrum disorders. The sample for
this study consisted of 2 young children with autism or
pervasive developmental disorder and their parents. Parents
and children received weekly intervention sessions for 8 to
14 months. These sessions focused on using a Responsive
Teaching curriculum. Comparison of pre and post assessment
indicated that the intervention was successful at
encouraging the mothers to engage in more responsive
interactions; increases in mothers’ responsiveness were
associated with significant improvements in children’s
social interactions, as well as in standardized measures of
social-emotional functioning. These results indicate that
relationship-focused intervention holds much promise for
enhancing the social-emotional features of children with
autism spectrum disorders.

Mahoney, G. & Perales, F. (2005) Relationship-focused early

intervention with children with pervasive developmental
disorders and other disabilities: A comparative study.
Journal of Developmental and Behavioral Pediatrics, 26, 77-
85

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.
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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.

Rogers, S. & Dilalla, D. (1991) A comparative study of the

effects of a developmentally based instructional model on
young children with autism and young children with other
disorders of behavior and development. Topics in Early
Childhood Special Education. 11,247

Progress reported in two groups of preschool children,

those with autism and those with other emotional/behavioral
disorders, in a particular instructional model were
reported. The model was developmentally based and heavily
influenced by Piaget’s theory of cognitive development and
Mahler’s theory of interpersonal relationships. Both groups
made greater progress than were predicted by their initial
developmental rates in cognitive and language areas. The
group with autism did not make less progress than the
comparison group, which ran contrary to the authors’
hypothesis.

Salt, J., Schemilt, J., Sellars, V., Boyd, C., Coulson, T.

& McCool, S. (2002). The Scottish Centre for Autism
Preschool Treatment Programme: II: The results of a
controlled treatment study. Autism, 6(1), 33-46.

This article evaluates the effectiveness of a

developmentally based early intervention program. Two
groups of children were compared, a treatment group and a
no-treatment (waiting list) group. Pre-treatment, the no-
treatment group had a significantly higher IQ, but was
otherwise matched for age, mental age, socioeconomic
status, and number of hours of non-experimental therapy.
Results showed the treatment group improved more
significantly on measures of joint attention, social
interaction, imitation, daily living skills and an adaptive
behavior composite. A measure of requesting skills fell
short of significance.

Solomon, R., Necheles, J., Ferch, C & Bruckman, D. (2008).

Pilot study of a parent-training program for young children
with autism: The P.L.A.Y. project home consultation
project. Autism, 11(3), 205-224.
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This study showed significant increases in children
subscale scores on the FEAS after a 12-month program using
Floortime. The P.L.A.Y. project created a manual, training
and evaluation method. Parents were encouraged to do 15
hours/week in one-to-one interactions with their child at
home. 12 children were enrolled in EI fro two hours/week;
56 children were enrolled in special education programs. No
child received more than 5 hours week of ABA at home. The
statistically significant findings were also clinically
significant. A gain of one or more functional levels within
an 8-12month period is clinically significant.

Wieder, S. & Greenspan, S.I (2005). 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,
Individualized-Difference, relationship-based (DIR)
approach. Journal of developmental and learning Disorders,
9, 39-61.

This describes 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.

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