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The Developmental, Individual-differences, Relationship-based (DIR) model is a developmental model for assessing and understanding any child's development. It has become particularly effective at identifying the unique developmental profiles and developing programs for children experiencing developmental delays due to autism, autism spectrum disorders, or other developmental disorders. This Model was developed by Dr. Stanley Greenspan and first outlined in 1979 in his book Intelligence and Adaptation. "The Play Project" - which is a DIR Floortime program and was developed by Richard Solomon, established evidence-based status for their approach through a 3-year study by NIMH which was published last year.
The Developmental, Individual-difference, Relationship-based (DIR) model is the formal name for a new, comprehensive, individualized approach to assess, understand, and treat children who have developmental delays (including Autism Spectrum Disorder). Focusing on the building blocks of healthy development, this approach is also referred to as the "Floortime" or "DIRFloortime" approach. However, Floortime is actually a strategy within the DIR model that emphasizes the creation of emotionally meaningful learning exchanges that encourage developmental abilities.
The goal of treatment within the DIR model is to build foundations for healthy development rather than to work only on the surface of symptoms and behaviors. Here, children learn to master critical abilities that may have been missed along their developmental track. For example, Autism Spectrum Disorder (ASD) has three core/primary problems: (1) establishing closeness, (2) using emerging words or symbols with emotional intent, and (3) exchanging emotional gestures in a continuous way. Secondary symptoms (perseveration, sensory-processing problems, etc.) may also exist. Thus, treatment options are based on particular underlying assumptions. The DIR model is based on the assumption that the core developmental foundations for thinking, relating, and communicating can be favorably influenced by work with children’s emotions and their effects.
The DIR model was developed to tailor to each child and to involve families much more intensively than approaches have in the past. Through the DIR model, cognition, language, and social and emotional skills are learned through relationships that involve emotionally meaningful exchanges. Likewise, the model views children as being individuals who are very different and who vary in their underlying sensory processing and motor capacities. As such, all areas of child development are interconnected and work together beneficially.
The Interdisciplinary Council on Development and Learning (ICDL) holds registered trademarks in the United States and/or other countries for DIR, DIRFloortime, and Floortime. www.icdl.com
DIRFloortime Model Milestones/Capacities
The DIR model is broken down into milestones (AKA capacities) (i.e., stages of development) that are gauged in normally developing children (versus children who have developmental delays).
In babies from 0 to 2 months, Milestone One involves self-control/self-regulation and interest in the world. The focus here is shared attention, which involves learning and interacting socially. Children need to learn to stay calm, to focus, and to actively take in information from their experiences with others.
Milestone Two occurs in ages 2 to 6 months. It involves relating and engagement whereby babies learn to recognize patterns, such as patterns of language in the flow of conversation. From there, they can internalize and process those patterns into something meaningful; for example, they understand cognitively that they can use language to obtain a desire.
Milestone Three involves intentional two-way communication and occurs by 6 months, when babies begin to convert emotions into signals for communication. But in order for this to happen, primary caregivers must read and respond to babies’ signals while also challenging the babies to read and respond to theirs.
Milestone Four involves social problem-solving, formation of a sense of self, and mood regulation, which occurs between 9 and 18 months. Babies use two-way communication to solve problems by employing patterns that involve a few steps to achieve a desired goal. For example, the baby can engage a parent and use eye gaze to get a desired goal or can grab a caregiver’s hand and pull toward his/her plate to indicate the desire for more food. Later, this process helps children to put words together into a sentence. Progress here is built on emotional interactions that increasingly become more complex.
Milestone Five occurs around age one, involving the creation of symbols and the use of words/ideas. "Using ideas" is defined as the meaningful use of pictures, words, or symbols to communicate something (in contrast to scripting or repeating).
Milestone Six, which occurs in toddlers around two years of age, regards emotional thinking, a sense of reality, and logic. Here, to create a new understanding of reality, one must logically connect his/her own idea to someone else’s. Emotional investment in relationships helps children to recognize the differences between their own and others’ ideas and behaviors.
Milestone 7 presents multi-causal and triangular thinking in which a child between ages 5 and 7 begins to recognize and process multiple causes for emotions and events.
During Milestone 8, between ages 7 and 10, emotionally differentiated thinking and gray-area thinking occur. Here, the child begins to understand the varying degrees or relative influences of events, feelings, or phenomena (e.g., "I’m only a little sad").
Last, Milestone 9, which arrives between puberty and early adolescence, involves a growing sense of self and reflection on an internal standard. This means that more-complex emotional interactions are helping the adolescent to progress into thinking in relation to an internal standard of an expanding self (e.g., "I was more angry than usual").
These nine functional emotional-developmental capacities continue to develop throughout life, but they need to happen sequentially, building upon the prior capacity, in order for the child to adapt and develop healthily.
DIRFloortime Model Approach
Floortime is a family approach because the entire family is challenged when an individual member has uneven development. Unfortunately, in the example of Autism Spectrum Disorder (ASD), children tend to be rigid as a way to cope with their developmental difficulties and their related emotional frustrations, and families can react just as rigidly when they actually should be flexible and open to help in offsetting the afflicted child’s rigidity. Thus, crisis tends to cause an "us versus them" mentality, which limits resources and creates stress. On the other hand, using the DIR Floortime model helps parents, caregivers, and other family members to consider their own behavioral patterns and beneficial reactions.
There are two goals in Floortime: (1) follow the child’s lead, and (2) bring the child into a shared world. To follow the child’s lead means to take the cue from the child, because a child’s interests are the window to his/her emotional life. From there, we can join the child in a shared world. The rationale here is that a child feels closer to someone who shows respect for the child’s interests and participates in them. Once a child enjoys having us participate with him/her, we can then begin to help the child toward greater development. Floortime leads us in going beyond by challenging the child to master each developmental level; it requires our attention to the child’s nervous system and individual processing abilities, to our own personalities and reactions to the child, and to our family’s patterns.
Floortime is a developmental intervention involving meeting a child at his or her current developmental level, and challenging them to move up the hierarchy of milestones outlined in the DIR Model. Floortime is child-focused—the parent or therapist follows the child's lead, with playful positive attention while tuning into the child's interests. Once the child connects with the adult specific techniques are used to challenges and entice the child to move up the developmental ladder. Dr. Stanley Greenspan and his wife Nancy described this intervention for the first time their 1989 book, The Essential Partnership. Floortime has since made its way into homes, clinics, schools and hospitals as an effective intervention for various types of learning and developmental challenges. Over the last 10 years significant research has been published internationally supporting Floortime.
The DIR model is based on the idea that due to individual processing differences children with ASD do not master the early developmental milestones that are the foundations of learning. DIR outlines six core developmental stages that children with ASD have often missed or not mastered:
- Stage One: Regulation and Interest in the World: Being calm and feeling well enough to attend to a caregiver and surroundings. Have shared attention.
- Stage Two: Engagement and Relating: Interest in another person and in the world, developing a special bond with preferred caregivers. Distinguishing inanimate objects from people.
- Stage Three: Two way intentional communication: Simple back and forth interactions between child and caregiver. Smiles, tickles, anticipatory play.
- Stage Four: Continuous Social Problem solving: Using gestures, interaction, babble to indicate needs, wants, pleasure, upset. Get a caregiver to help with a problem. Using pre-language skills to show intention and become a creative and dynamic problem solver.
- Stage Five: Symbolic Play: Using words, pictures, symbols to communicate an intention, idea. Communicate ideas and thoughts, not just wants and needs.
- Stage Six: Bridging Ideas: This stage is the foundation of logic, reasoning, emotional thinking and a sense of reality.
Most typically developing children have mastered these stages by age 5 years. However, children with ASD struggle with or have missed some of these vital developmental stages. When these foundational abilities are strengthened through the child's lead and through meaningful play with a caregiver, children begin to climb up the developmental ladder.
Evidence Base for the DIRFloortime Model
Four randomized-controlled studies were published since 2011 identifying statistically significant improvement in children with autism who used Floortime (Sealy & Glovinsky, 2016; Solomon, et. al., 2014; Casenheiser, Shanker & Steiben, 2011; Lal and Chhabria, 2013; Pajareya and Kopmaneejumruslers, 2011). These studies also showed the effectiveness of addressing the caregiver (Solomon, et. al., 2014; Casenheiser et. al., 2011) and specific skill improvement including turn taking, two way communication, understanding cause and effect and emotional thinking (Lal and Chhabria, 2013).
Solomon, Necheles, Ferch, and Bruckman (2007) conducted a pre-post survey of the Play and Language for Autistic Younsters (PLAY) Project Home Consultation program. This program, based on the DIR model, is used in fifty agencies across seventeen U.S. states. Results indicated statistically significant improvement in the children’s Functional Developmental Levels and 100% of the parents reported satisfaction in participating.
In 2002, a pre/post-randomized controlled trial utilizing an approach based on developmental, individual-differences, and relationship-based philosophy was published by Salt, Shemilt, Sellars, Boyd, Coulson and Mc Cool. The study showed not only statistically significant improvement in specific skill development, but also that caregivers reported a decrease in stress with treatment while the control group showed an increase in stress.
Case studies have also been effective in supporting the use of DIRFloortime with children with autism. Dionne and Martini (2011) demonstrated statistically significant improvement in communication between parent and child. Wieder and Greenspan (1997, 2005) did comprehensive case studied that spanned from 8-15 years. These studies supported the long lasting results DIRFloortime had on individual child skills, as well as, the emotional connections the families were able to develop over time using this approach.
Floortime and related DIR based approaches are listed on evidence-based treatment reviews. Most recently, the Journal of Clinical Child and Adolescent Psychology published an article entitled, "Evidenced Base Update for Autism Spectrum Disorder" where they categorized Floortime as a "Developmental Social Pragmatic (DSP) Parent Training" and listed focused DSP Parent Training in their second level evidence base category indicating it as "Probably Efficacious." (Smith & Iadarola, 2015) Several recent studies on Floortime were cited in the article including the recent randomized clinical trial studies. The research is beginning to catch up with what we have known in practice for many years.
Some people have referenced the National Autism Center's National Standards Project that has listed Floortime as "unestablished." It is very important to note that the National Autism Center is a part of the May Institute and is not an independent entity. This is a $103 million a year service provider with 150 service sites around the country where they are apparently providing primarily behavioral approaches. The board of the National Standards Project is dominated by professionals that work from a behavioral perspective, primarily ABA. This report has many flaws and is not objective. The 2015 report is also conveniently based on old research that precedes much of the DIR focused research that has come out in the recent years. Because they are using the name "National Autism Center" some have assumee they are an independent body. The May Institute is a very large service provider with clear conflicts of interest.
Structure of DIRFloortime Model
The DIRFloortime Model works in two general parts: Assessment and Intervention. Within each of these two categories, there are further steps and strategies.
The initial step for assessment is [Screening]. The creator of the DIRFloortime Model, Dr. Stanly Greenspan, developed a measuring tool, the Greenspan Social-Emotional Growth Chart (GSEGC), to aid parents, caregivers and clinicians in this beginning step of assessment. This tool is a basic 35-item questionnaire that evaluates a child according to the social-emotional milestones he or she has met. This preliminary step is a quick method to screen children for risk or diagnosis of Autism Spectrum Disorder (ASD) or Pervasive Developmental Disorder (PDD).
Following the initial screening process is conducting a [Comprehensive Functional Developmental Evaluation]. A child that has been screened with the GSEGC and displays significant developmental delay will then proceed to this step. In this process, a single clinician or clinicians of multiple disciplines (i.e. pediatrics, speech therapy, occupational therapy, psychology, etc.) must spend a significant amount of time observing a child. Specifically, the clinician(s) must be able to characterize how the degree to which a child is able to interact with others as it relates to developmental level.
In the final step of Assessment an [Individual Developmental Profile] is created based on the Comprehensive Functional Developmental Evaluation performed on the child. This profile is made to characterize a child’s socio-emotional capacities. Through this profile, the DIRFloortime Model is able to tailor its intervention strategies uniquely to each child.
Once the Assessment phase is completed the Intervention period is initiated. There are four different areas that the DIRFloortime Model aims its interventions: 1) Home 2) Educational Programs 3) Therapies 4) Play Dates.
First, the strategies and exercises laid out in the Home Intervention are of great importance for a child. It involves three core interactions: floortime; semi-structured, problem-solving interactions; and motor, sensory, perpetual-motor, and visual-spatial physical activities.
|Floortime||Play with child by following his or her lead|
|Semi-structured Problem Solving||Create tasks that build of the child’s interests to encourage and nurture his or her problem solving skills|
|Motor, Sensory, and Perceptual-Motor Activities and Visual-Spatial Activities||Engage child in activities that are tailored to his or her unique needs as it relates to motor, sensory, and perceptual-motor and visual-spatial activities|
Second, interventions can also be applied through Educational Programs. Just as in the Home Interventions, the three core interactions are utilized in schools. Instead of primary caregivers carrying out these interactions it will be the responsibility of the teachers, teacher assistants, or peers. As an added efficiency measure, Individualized Educational Plans (IEP) can be collaboratively created and tailored for a child by his or her primary caregivers, teachers, or clinician. The IEP is developed with the purpose of outlining the goals of improvement for a child’s specific developmental needs.
Another component of the DIRFloortime Model Intervention is a multi-disciplinary approach through different therapies. According to a child’s Individual Developmental Profile, primary caregivers or clinicians can determine what types of therapy will benefit a child based on his or her developmental need. Such therapies can include working with a speech therapist, occupational therapist, clinical psychologist, etc.
The final intervention component of the DIRFloortime Model is Play Dates. While it is extremely important for a child to develop strong and healthy relationships with his or her primary caregiver(s), it is also essential to encourage play dates with other children. However, this step must be taken when the child is able to securely interact with others and is beginning to build his or her capacity for imitation and problem-solving skills. These play dates will benefit and support the child for continued success in these mentioned areas.
- The P.L.A.Y. Project a program based on floortime
- Cullinane, MD, Diane. Behavioral Challenges in Children with Autism and Other Special Needs:. NYC, New York: W,W.Norton and Company. ISBN 0393709256.
- "Autism Spectrum Disorder: Signs and Symptoms". CDCgov. Center For Disease Control. Retrieved 24 July 2016.
- Greenspan, Stanley (2004). "Greenspan social-emotional growth chart: A screening questionnaire for infants and young children". PsychCorp.
- "Guidelines for a Comprehensive DIR Program". The Interdisciplinary Council on Development and Learning. The Interdisciplinary Council on Development and Learning, Inc. Retrieved 24 July 2016.
- Greenspan, Sidney. "Basic Course Lecture Series--Lecture 7--Comprehensive DIR Assessment" (PDF). The Greenspan Floortime Approach. Retrieved 24 July 2016.
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