Journal of Occupational Therapy, Schools, & Early

Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: https://www.tandfonline.com/loi/wjot20

Qualitative Research: Perceptions of the

Developmental, Individual Differences,
Relationship-Based (DIR) Model among Preschool
Staff in a Public-School Setting

Susan Smith-Foley & Winnie Dunn

To cite this article: Susan Smith-Foley & Winnie Dunn (2019): Qualitative Research: Perceptions
of the Developmental, Individual Differences, Relationship-Based (DIR) Model among Preschool
Staff in a Public-School Setting, Journal of Occupational Therapy, Schools, & Early Intervention,
DOI: 10.1080/19411243.2019.1647812

To link to this article: https://doi.org/10.1080/19411243.2019.1647812

Published online: 01 Aug 2019.

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JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
https://doi.org/10.1080/19411243.2019.1647812

Qualitative Research: Perceptions of the Developmental,

Individual Differences, Relationship-Based (DIR) Model among
Preschool Staff in a Public-School Setting
Susan Smith-Foley, MPA, OTR/La and Winnie Dunn, PhD, OTR/L, FAOTAb
a
Doctoral of Occupational Therapy Program, The University of Kansas Medical Center, Kansas City, Kansas,
USA; bDepartment of Occupational Therapy, University of Missouri, Columbia, USA

ABSTRACT ARTICLE HISTORY

The Developmental, Individual Differences, Relationship-Based (DIR) Received 18 November 2018
model, also known as DIR®/Floortime™, is a comprehensive approach Accepted 22 July 2019
for individuals with developmental disabilities and other disorders of KEYWORDS
relating and communicating, including autism spectrum disorder (ASD). DIR model; special
Limited qualitative research exists regarding the use of the education; occupational
Developmental, Individual Differences, Relationship-Based (DIR) model therapy
in public preschools. The purpose of this qualitative research project is
to increase understanding of the use of this model in preschool and early
childhood settings through the perspective of those who utilize this
approach.
Method: Researchers recruited preschool staff from DIR classrooms
to participate in a focus group. Participants included 5 special educa-
tion teachers, 2 paraprofessionals, and 1 speech language patholo-
gist; all were female.
Results: Three themes emerged: participant insight, processes and
procedures that enable successful use of the DIR model in a public
preschool setting, and challenges with use of the DIR model in
a public preschool setting.
Conclusion: Findings from this study may be beneficial to new DIR
preschool staff and administrators and may serve as a guide to other
public preschool teams who are considering or have DIR-focused
classrooms. Opportunities exist for occupational therapists to add
distinct value to DIR preschool programs.

Introduction
The Developmental, Individual Differences, Relationship-Based (DIR) model, also known as
DIR®/Floortime™, is a comprehensive approach for individuals with developmental disabilities
and other disorders of relating and communicating, including autism spectrum disorder (ASD).
This model developed by Stanley I. Greenspan, M.D. and Serena Wieder, Ph.D. serves as
a framework for understanding functional emotional development in children and adults. The
influence of biological individual differences, such as sensory processing capacities, language
processing and communication, motor competencies, and visual spatial processing, on devel-
opment is a key aspect of the model (Greenspan & Wieder, 1998; Ryan, Hughes, Katsiyannis,
McDaniel, & Sprinkle, 2011; Wieder & Wachs, 2012). Primary relationships including parents,
other family members, and school caregivers are integral to the model and considered essential to

CONTACT Susan Smith-Foley avonot@hotmail.com Doctoral of Occupational Therapy Program, The University of
Kansas Medical Center
© 2019 Grace Scientific Publishing, LLC
2 S. SMITH-FOLEY AND W. DUNN

the child’s development. Educational programs that utilize the DIR model create learning
interactions tailored to the unique needs and individual differences of the student while
simultaneously using student interests in open-ended, semi-structured, and structured ways
(Greenspan & Wieder, 2006; Wieder & Kalmanson, 2000).
Educating children with ASD requires careful consideration of individual student needs
(Scheuermann, Webber, Boutot, & Goodwin, 2003). Best practices indicate that no single
methodology be used indiscriminately with students with ASD (Scheuermann et al., 2003;
Shyman, 2012). Zachor, Ben-Itzchak, Rabinovich, and Lahat (2007) identified the
Developmental approach, DIR, Treatment and Education of Autistic and Related
Communication Handicapped Children (TEACCH), and Applied Behavioral Analysis
(ABA) as the main intervention approaches for students with ASD. The DIR model serves
as an alternate or complementary approach to behavioral teaching programs (Ryan et al.,
2011; Shyman, 2012).
Occupational therapists are integral members of classroom teams who support students
with ASD and other developmental and learning challenges. The Occupational Therapy
Practice Framework: Domain and Process, 3rd edition, also referred to as the Framework
describes occupational therapy practice and guides practitioners in their daily work with
clients (American Occupational Therapy Association, 2014). Additional practice guide-
lines exist for occupational therapy practitioners who work with individuals with ASD and
include a review of interventions within the boundaries of acceptable practice (American
Occupational Therapy Association, 2016).
The Domain and Process of occupational therapy appear to align with the DIR model
in several ways. The Domain provides an understanding of the whole person in mean-
ingful occupations and contexts and environments of his or her daily life. Client factors,
such as body structures and performance skills, such as motor and process skills, appear to
correlate to individual differences in the DIR model. The Process of occupational therapy
embodies client-centered practice in the evaluation and intervention process and colla-
boration between client, caregiver, and family (AOTA, 2014), as does the DIR model.
Social relationships, social participation, and their dynamic interplay are fundamental to
the Domain and Process of occupational therapy and to the DIR model.
Use of available evidence to guide clinical reasoning is inherent to the Framework and to
occupational therapy practice. Qualitative research and quantitative research methods have
different strengths and weaknesses (Patton, 2015).

Qualitative research facilitates “understanding of phenomena of interest from the perspective

of those who experience it” (Mills & Birks, 2014, p. 260) in the context in which it occurs
(O’Brien, Harris, Beckman, Reed, & Cook, 2014).

A growing body of quantitative research exists regarding the efficacy of the DIR model,
DIR/Floortime, and Developmental-Relationship Based Interventions for children with
autism (Cullinane, Gurry, & Solomon, 2017). In contrast, an extensive literature review
germane to use of the DIR model in public schools yielded only two relevant qualitative
research studies.
The first is an exploratory qualitative study conducted by Hebert (2014) that investi-
gated the reasons behind parents’ decisions about interventions for their child with
autism. Parents expressed having to choose between two philosophical approaches at
the time of diagnosis: ABA or DIR. Similarly, parents had to make a philosophical
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 3

preschool program choice when their child aged out of early intervention. Three main
parent themes emerged in the selection of the philosophical approach and type of pre-
school program: parental attributes, child’s attributes, and program attributes.
The second qualitative study conducted by Iadarola et al. (2015) examined the percep-
tions of stakeholders (parents, educators, and school administrators) in three large, urban
school districts regarding services for students with ASD within the context of limited
district resources. While not specific to use of the DIR model in preschool or early
childhood settings, this study describes overarching concerns regarding the use and
perception of services for students with ASD in public school districts.
In summary, limited qualitative research exists regarding the use of the DIR model in
public preschools. The purpose of this qualitative research project is to increase under-
standing of the use of this model in preschool and early childhood settings through the
perspective of those who utilize it.

Approach
Method
Researchers in this study include Winnie Dunn, Ph.D., OTR/L, FAOTA, Principal
Investigator (PI) and Susan Smith-Foley, MPA, OTR/L, Co-Investigator (Co-I). Co-
Investigators participate in the scientific development and execution of a research project,
including the reporting of findings (Geisinger Health, 2019).
The researchers employed a focus group format to collect qualitative data. Focus groups
are a flexible qualitative research methodology utilized in many different settings and
ways, including as a preliminary design, as a component of larger qualitative studies, to
gain participant perspectives on a particular area of study, or to augment quantitative
research (Clark-Jones & Broome, 2001; Peterson-Sweeney, 2005). Focus groups typically
include a moderator (Patton, 2015), participants who have something in common relevant
to the study’s questions (Marshall & Rossman, 2016), and are comprised of four to twelve
members to produce rich empirical research (Peterson-Sweeney, 2005).

Procedures
The University of Kansas Medical Center Institutional Review Board Human Subjects
Committee (HSC) approved the research purpose, design, methods, and use of human
subjects for this study. The researchers also obtained written approval from the school
district in which the focus group occurred. They employed convenience sampling in
a public preschool center that utilizes the DIR model.
Researchers recruited teachers, paraprofessionals, occupational therapists, speech language
pathologists, physical therapists, and child study team members through electronic corre-
spondence using an approved letter. Inclusion criteria included: preschool staff members who
worked in a DIR-focused public preschool classroom for a minimum of 10 cumulative
months; had some level of staff training and/or formal continuing education on the DIR
model; and were able and willing to communicate their perceptions in a group forum. This is
in accordance with Patton (2015) who recommends that individuals with homogeneous
backgrounds comprise focus groups. Exclusion criteria included: preschool staff members
4 S. SMITH-FOLEY AND W. DUNN

who had less than 10 months of cumulative experience in working in a DIR-focused class-
room; did not have any staff training and/or formal continuing education on the DIR model;
and were unable or unwilling to communicate their perceptions in a group forum.
The Co-I conducted consent interviews with each interested participant and obtained
necessary written consent for voluntary participation in the focus group meeting.
Collection of basic demographic information occurred during the consent interviews
with removal of identifiers prior to the actual focus group meeting. Each participant
received a reminder of the focus group meeting day and time via email correspondence.
Adherence to data management and security procedures were in alignment with The
University of Kansas Medical Center Institutional Review Board Human Subjects
Committee throughout the study.
The Co-I moderated the focus group meeting using an approved question guide. The
meeting was audio recorded and lasted just over an hour. Moderator techniques included
refraining from conveying personal views or experiences, treating each participant with
respect, engaging in active listening, and thanking each person for their input and
participation as recommended by Krueger and Casey (2002) and Peterson-Sweeney
(2005). The Co-I maintained a reflexivity matrix as described by Rae and Green (2016)
throughout the research project to minimize the potential for bias during pre-research,
data collection, and data analysis. Additionally, the researchers maintained an audit trail
and used the Critical Appraisal Skills Programme Qualitative Research Checklist (2017) to
ensure rigor and accountability. The Standards for Reporting Qualitative Research
(O’Brien et al., 2014) served as an overarching guide to this research project.

Data Analysis
For this study, a professional transcribed the audio recording from the focus group
meeting verbatim. The researchers used a four step process to analyze data which included
review, organization, coding, and interpreting as described by the Centers for Disease
Control and Prevention (2009). They reviewed the content multiple times to ensure
accuracy and gain familiarity with the responses. Manual data analysis and coding of
data entailed an iterative process which included highlighting key phrases and making
notes in the margins of the transcript (Rabiee, 2004; Smith & Firth, 2011), use of direct
quotes (in-vivo codes) to synthesize and present findings (Morrison-Beedy, Côté-
Arsenault, & Feinstein, 2001), and review of moderator reflections to augment the written
transcript (Rabiee, 2004). Analysis and organization of responses from each focus group
question occurred through the set-up and use of a Microsoft Word table with the
following headings: distillation of responses, in-vivo codes as applicable, preliminary
analysis/initial categories, and key themes. Extensive review and analysis of this document
led to further integration and synthesis of themes.

Results and Discussion

Eight preschool staff members met the inclusion criteria and were available to participate
in a focus group meeting held in June, 2018. Participants included 5 special education
teachers, 2 paraprofessionals, and 1 speech language pathologist; all were female.
Scheduling conflicts impeded participation of occupational therapists and physical
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 5

therapists in this study. The mean length of time using the DIR model with preschool
students was 5.66 years.
Three themes emerged from the focus group meeting. The first theme relates to
participant insight. The second theme relates to processes and procedures that enable
successful use of the DIR model in a public preschool setting. The third theme relates to
challenges with use of the DIR model in a public preschool setting.

Participant Insight
Participants traced their interest in DIR to earlier pre-professional and professional
experiences. Pathways to developing expertise in the model occurred along a continuum
of learning experiences, ranging from less formal to more formal learning experiences,
including DIR Certification. Participant discussion sparked reflection of prior training in
other models and approaches including learning about and use of ABA. This information
differed from information gathered by the Co-I during the Consent Interview process in
which only one person reported receiving training on ABA and only one person reported
prior use of ABA.
Key “aha” moments existed among public preschool staff when learning about or
utilizing the DIR model. These moments appeared to underscore their desire to utilize
an individualized, bottom-up, developmental approach that considers the developmental
readiness and individual needs of each preschool student. Focus group participants
expressed that emphasis is on establishing relationships, sensory and emotional regulation,
fostering intentionality, language development that targets non-verbal, gestural commu-
nication in addition to verbal communication, joining the child in meaningful activities
and play experiences, and the provision of interventions within the zone of proximal
development. One participant stated that “I feel like the DIR model really, really taught me
how to meet a child in the zone of proximal development and give him like the just right
challenge to move him up.” Another participant expressed that the DIR model “taught me
to understand my own regulation” to more effectively support student and staff regulation
in the classroom.

Procedures and Processes that Support DIR

Many of the participants articulated the importance of having a preschool supervisor who
has knowledge of this developmental model; who understands and supports individualized
classrooms, curriculum, and interventions; and who provides professional support and
guidance as is the case in their preschool setting. “So, the fact that we have a supervisor
who gives us that support and that allows us to create classrooms like this is, is a huge,
huge thing.”
Participants perceived it to be easier to implement the DIR model at the preschool level
in public school in terms of being able to readily implement environmental modifications
in the classroom, match individual needs to the curriculum, and to be physically able to
meet the needs of smaller students. “I think we have a benefit over elementary schools,
because we can create microenvironments in the classroom that meet our children’s
sensory profile, you know, a quieter corner.” The age of preschool students is also positive
6 S. SMITH-FOLEY AND W. DUNN

due to their openness to learning and the likelihood of less prior “negative learning
experiences.”
Several participants reflected on their own growth in understanding the importance of
intentionality when using the DIR model with preschool students. This involves both
observing and creating opportunities for preschool students to be intentional; staff slowing
their pace and scaling back on all of their own intentions, language, and ideas; and
requires patience and training from more experienced DIR-trained staff. Moreover, “one
of the biggest things I had to learn was how to help a child feel empowered to have
intentionality.” Another participant expressed that when you see that a child “wants
something, we say it, and then it helps us connect to their inner world, and they feel
understood.” Self-reflection is a process utilized by DIR preschool staff.
Focus group participants also indicated that the DIR model is applicable to school
and home settings and transfers readily from one setting to another. Parents benefit
from coaching on “what we do at school” which “benefits the whole family
connection.”
Participants expressed that student progress in DIR classrooms can be determined
through qualitative and quantitative measures. General consensus indicated the need for
continued professional growth and interdisciplinary collaboration in application of the
DIR model in a public preschool setting. Participants also conveyed that a need exists for
training on the DIR model to the entire preschool staff as students in DIR-focused
preschool classrooms have contact with other teachers and paraprofessionals in other
school environments such as the playground. Lack of understanding may result in staff
just “reacting to a behavior, when they don’t know where that behavior is coming from in
the first place, like a child who’s hitting.” The DIR model considers the underlying cause
of behaviors such as over responsiveness to the sights, sounds, touch, and unpredictable
movements of peers on a busy playground. Redirection to a quiet area of the playground
with an attuned staff member is one example of how hitting might initially be addressed
through the lens of the DIR model.

Challenges with Implementation of DIR

Participants identified temporal and environmental challenges in terms of adherence to
overarching classroom or therapy schedules that may not match the needs of a particular
child, as well as sharing of space and materials. Participants also described challenges with
staffing. “It’s very, very challenging because you have nine, twelve, whatever students in
your classroom, you can’t split yourself into nine pieces” to meet the unique profiles and
often competing needs of students. This results in staff working with multiple children at
the same time while prioritizing the focus on one or two children in the group. “I as
a teacher feel like I need to have the opportunity to work one-on-one with the children
more, because otherwise … my hands are tied behind my back.”
Participants discussed challenges with creating DIR-focused IEP goals and objectives,
tracking and measuring progress within existing documentation systems, and articulating
qualitative progress. “Floortime doesn’t lend itself to ‘quant’ quantitative data. In order to
really track what you’re doing, it has to be more qualitative.” This is “much more time-
consuming” and “much more difficult to accomplish in the classroom.” As a result,
utilization of multiple data collection systems occur including quantitative ratings of
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 7

IEP goals and objectives, use of video tape analysis to measure progress in social emotional
development, and anecdotal observations of the student.
Much discussion focused on parent, school, and administrator training on the DIR
model. Focus group participants expressed the need for parent training and communica-
tion to be conducted on a consistent basis with staff who know the child, including having
the parents “actually come into the classroom.” Related to this, was the concern that
limited understanding of the model exists by others “outside our little bubble of peers”
and immediate supervisor. “We’ve accomplished so much, we work so hard, and people
come into the classroom like, what are you doing? What are you accomplishing? And
what on earth … is going on in the classroom? And the fact that what you’re doing is so
not acknowledged, understood, or appreciated makes it very hard.”
Despite challenges, none of the participants expressed a desire to change use of the DIR model
with their students. One participant expressed “I can’t imagine teaching preschool any other way.
It’s the only thing that makes sense to me. You cannot expect a child to learn what they’re not
ready to learn. And if a child is locked in their own world, they’re not going to learn anything.”
At the conclusion of the focus group participants articulated their final take away
points. These included, 1) keep inspiring yourself to ask “why,” 2) pursue professional
development on the DIR model, 3) engage in interdisciplinary collaboration, 4) respect the
child and develop trust, 5) create positive, warm, and individualized learning environ-
ments, 6) reflect on student progress over the course of the school year using qualitative
and quantitative data, 7) be creative with existing time, resources, and solutions, 8)
celebrate student success, and 9) build on each developmental increment.

Application of Focus Group Findings to Occupational Therapy Practice

Findings of this qualitative research project do not include the perspectives of occupational
therapists. Despite this, results serve to inform occupational therapists of participant insight,
the processes that support the use of the DIR model in a public preschool, and the perceived
challenges. This information may augment existing clinical reasoning when working with
preschool students with ASD and other developmental challenges. Occupational therapists
can pursue advanced training in this model through such organizations as Profectum
Foundation, The Floortime Center, and The Interdisciplinary Council on Development and
Learning, Inc. They can serve as integral members or leaders of DIR-focused classroom teams.
Occupational therapists contribute to publications and journal articles regarding the
base of knowledge, use, and efficacy of the DIR model. Examples include the following.
Williamson, Anzalone, and Hanft (2000) published a chapter on the assessment of sensory
processing, praxis, and motor performance in The Interdisciplinary Council on
Developmental and Learning Disorders (ICDL) clinical practice guidelines. DeGangi
(2000) also authored a chapter on treating children with regulatory, sensory processing,
and interactional problems in this same publication. Greenspan, DeGangi, and Wieder
(2001) published The Functional Emotional Assessment Scale (FEAS) for Infancy and
Early Childhood: Clinical and Research Applications. Case-Smith and Arbesman (2008)
published an evidence-based review of interventions for autism in the American Journal of
Occupational Therapy. Dionne and Martini (2011) published a single-subject case study
on the use of Floortime in the Canadian Journal of Occupational Therapy. The final
example is Liao et al. (2014) who studied the effects of DIR/Floortime home intervention
8 S. SMITH-FOLEY AND W. DUNN

program on social interaction and adaptive functioning on 11 children with ASD and their
mothers.

Limitations of Focus Groups and This Qualitative Study

Potential limitations exist in generalizing findings from this qualitative research study due
to the small sample size and participants being from one site. Patton (2015) indicates that
focus groups appear to work best when members share a common background but do not
know each other. In this study all of the participants knew each other. The use of
convenience sampling in this study may also threaten validity. Sampling beyond the
preschool staff in this school district is something for the researchers to consider as this
option becomes available. There are currently no other public-school districts in New
Jersey that are using the DIR model to the same extent. One other possible limitation to
consider is focus group participants might not have felt comfortable in discussing all their
concerns with the Co-I given her dual role as moderator and DIR Consultant.

Conclusion
This qualitative research project utilized a focus group to study perceptions of the use of
the DIR model among public preschool staff. Findings from this qualitative research
project may be beneficial to new DIR preschool staff, staff and administrators external
to DIR preschool classrooms, and may serve as a guide to other public preschool teams
who are considering or have DIR-focused classrooms. Occupational therapists are integral
members of classroom teams who support students with ASD and other developmental
and learning challenges. Opportunities exist for occupational therapists to add distinct
value to DIR preschool programs through their comprehensive understanding of the
whole person, their ability to engage in clinical reasoning, and their ability to create and
integrate research into everyday practice.

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