By
Robert K. Ross, EdD., BCBA-D, LABA
Beacon ABA Services of MA and CT
&
Kelley L. Harrison, MA, BCBA, LBA-KS
Thomas Zane, PhD, BCBA-D
Department of Applied Behavioral Science, University of Kansas
Research has repeatedly demonstrated the benefits of early intensive behavioral intervention (EIBI) for children diagnosed with autism spectrum disorders (ASD; e.g., Lovaas 1993). Behavior therapists who provide EIBI often work in settings where a multi-disciplinary approach to treatment is used. It is not uncommon for behavior therapists to collaborate with colleagues from other disciplines (e.g., speech and language, physical therapy, occupational therapy). Although the multi-disciplinary approach can be beneficial, it may be detrimental if the proposed treatment in addition to EIBI is provided for multiple hours on a daily basis, as this can diminish available time for EIBI treatment. One increasingly popular approach to working with children with autism is the Developmental, Individual Difference, Relationship-based/Floortime (i.e., DIR/Floortime) model.
What is the conceptual link between ASD and DIR/Floortime?
The DIR/Floortime model was developed by Dr. Stanley Greenspan and Dr. Serena Weider (Greenspan & Wieder, 1999). It is based on a hypothesis that ASD is acquired as a result of a child’s early environment not providing specific kinds of emotional nurturing. This leads to them missing one or more of the six hypothesized emotional developmental milestones. DIR is described by proponents as a child directed “process or concept, through which therapists, parents, and other caregivers make a special effort to tailor interactions to meet the child at his unique functional developmental level and within the context of his processing differences” (Hess, 2009). It considers the “Development of functional emotional capacities, Individual processing differences, and the parent or caregiver-child Relationship” to create new learning opportunities and centers around circles of communication. A circle of communication involves two participants who respond to each other verbally or nonverbally (Dionne & Martini, 2011). DIR proposes six developmental milestones that create the foundation for a child’s learning and development. Specifically, the milestones are 1) self-regulation or interest in the world, 2) engagement and relating, 3) two-way intentional communication, 4) purposeful complex problem solving communication, 5) creating and elaborating ideas, and 6) building bridges between ideas (Wieder & Greenspan 2003).
Each milestone increases the length and complexity of the circle of communication. Floortime is the intervention technique used to facilitate mastery of the DIR developmental milestones. Specifically, Floor time involves guiding the child through the developmental milestones by following the child’s lead through play. That is, the therapist or caregiver will build on the child’s current skills to create more complex circles of communication. Proponents of Floortime suggest it facilitates generalization because each interactive circle of communication is created in a natural environment. Additionally, family involvement is a large component of Floortime, again to facilitate generalization (Dionne & Martini, 2011). Proponents recommend that DIR/Floortime be implemented in 20-minute blocks of time for six to ten sessions per day.
Is there any research to support Floortime?
Currently, research is limited on the use of Floortime to treat ASD (National Research Council, 2001). Additionally, the available research findings lack empirical validity (i.e., the experimental rigor of the available research is weak). In general, Floortime studies focus on training parents and therapist to implement Floortime interventions and evaluating the fidelity of the training on the interventions (e.g., Solomon, Van Egeren, Mahoney, Quon Huber, & Zimmerman, 2014). Although many of the studies look at changes in the hypothesized milestones developed by Greenspan and colleagues, to date none of the studies have evaluated the effects of Floortime on standardized measures of development or language. The studies have additional concerns. For example, one of the first studies to evaluate Floortime as an intervention for children with ASD was completed by Greenspan & Wieder in 1997. These authors retrospectively evaluated the charts of 200 children ages 22 to 48 months, who were diagnosed with ASD or pervasive developmental disorder not otherwise specified (PDD-NOS). All children were provided the Floortime intervention for two to five hours per day for two or more years by family or professionals. Outcomes of the intervention were determined using parental and therapist report to complete the Functional Emotional Assessment Scale (FEAS), a nonstandardized observation tool created by Greenspan and Wieder to assess the emotional functioning of a child based on the six developmental milestones that guide treatment in DIR. Greenspan and Wieder suggested 58% of the children had “good to outstanding” outcomes. That is, 58% of the children demonstrated 50 spontaneous circles of communication, mastered all six milestones, and created or participated in pretend play (Greenspan & Wieder, 1997). These results may at first glance seem promising; however, the lack of experimental control, experimenter bias, and use of non-standard measures greatly limits these findings. First, all outcomes were based on information found in a child’s chart (i.e., therapist and parental report) as opposed to direct observation. Second, a subjective observational tool was used to determine treatment outcomes. Both the reliance on anecdotal report and the use of a subjective observational tool allow for results to be greatly affected by biases. Third, the authors do not clearly describe the comparison group that was meant to serve as a control. Therefore, it is unclear if any treatment gains on standardized measures of development and language actually occurred due to the Floortime treatment.
In 2007, Solomon, Necheles, Ferch, and Bruckman evaluated the effects of parents using the DIR/Floortime model with 68 children over an 8-12 month period. Floortime was delivered 15 hours per week.
Treatment outcomes were determined using blind raters who scored videos of each child before and after treatment using the FEAS (again no standardized measures of development were assessed). Results suggested 45% of the children made good to very good functional developmental progress on the FEAS. However, much like Greenspan and Wieder (1997), Solomon and colleagues (2007) were lacking a control group and used a subjective measuring tool. Additionally, many of the participants in this study were simultaneously enrolled in other early educational programs. Therefore, it is unclear whether the increase in functional development should be attributed to Floortime or other outside educational programs.
In 2011, Dionne and Martini attempted to control for several of the limitations present in previous research by evaluating Floortime using a single-subject AB design with one boy age 3 years and 6 months with a diagnosis of autism. During Phase A (observation), the parent simply interacted with the child naturally and did not implement Floortime. During Phase B (intervention), Floortime was implemented by the parent. Phase A and Phase B were completed back-to-back a total of 28 times. Two blind observers watched 20 minutes of each phase for all 28 sessions and coded the number of circles of communication during each phase. Results were evaluated using visual analysis as well as statistical analysis. The authors concluded that the results of the visual analysis demonstrated great variability in the number of circles of communication observed during Phase A and Phase B, making a trend difficult to determine. However, there was a slight increase in the number of circles of communication observed during Phase B as compared to Phase A. Additionally, a statistical analysis of the number of circles of communication in Phase A as compared to Phase B showed a significant increase during Phase B as compared with Phase A. Although the use of the AB design increases experimental control as compared to previous research, it is still extremely limited because the results were never replicated either with the current participant or across other participants. Therefore, additional research that evaluates the effects of Floortime on standardized measures of development and language is still needed to determine if the Floortime treatment model has any significant impacts on the core diagnostic features of ASD, particularly when compared to treatments that have already been shown to have such effects. Pajareya and Nopmaneejumruslers (2011) conducted what they described as a pilot study to assess the extent (if any) to which DIR/Floortime would enhance client outcomes of children with autism who were already involved in other clinical interventions. The researchers trained parents to conduct the treatment. Two groups of participants were involved – both groups were already receiving one-to-one behavioral treatment (discrete trial teaching); the experimental group supplemented that treatment with DIR/Floortime hours. The experimental design was pre/post test (or AB), with global assessments being made at the start and end of the experiment. The results showed a significant improvement in scores in the children who were treated by both DIR/Floortime and behavioral interventions. However, there were several methodological flaws that suggest skepticism in any causal relationship between DIR/Floortime and a reduction in autistic symptomology. First, there is the obvious influence of behavioral treatment in the group of children receiving DIR/Floortime. Second, the authors admitted that some of the parents of these children had to be taught how to play with their children, irrespective of the DIR/Floortime procedures. Third, there was no direct observation check on the fidelity of the parents implementing the DIR/Floortime procedures. That is, there is no proof that parents actually implemented the Floortime procedures as required. In a related study, Solomon and colleagues (2014) recently investigated the impact of DIR-type procedures when training parents to implement with their young children diagnosed with autism. Mixed results were obtained, with the strongest data showing superiority of DIR coming from changes in scores on the Autism Diagnostic Observation Schedule-Generic (ADOS-G). However, there were several limitations with this research, including the use of statistical analyses as opposed to direct observation of behavior, use of self-report survey data of questionable reliability and validity, and a lack of verification that parents actually implemented the required protocols.
Future Research
The current research on DIR/Floortime is lacking in experimental control and empirical validity and objective measurement of treatment effects. Therefore, future research is needed to evaluate the efficacy of DIR/Floortime as a treatment for children with ASD. One major barrier to evaluating DIR/Floortime as a treatment is the subjectivity of the treatment itself. Currently, operational definitions/descriptions of both the procedures and the outcome measures are lacking and are inherently subjective, making replicating of identical procedures almost impossible. However, if more objective procedures could be identified, more research like Dionne and Martini (2011) may lend information on the effects of DIR/Floortime as a treatment for ASD. Specifically, future research should continue to utilize the within-subject research design to control for individual differences across participants and continue to measure results by collecting data on the effects of observable behaviors such as circles of communication or standardized measures of learner development. Additionally, future research should replicate results both within and across participants. Finally, future research may consider replicating results using different populations such as different age groups or different severities of delay as well as replicating results when treatment is delivered by trained therapists or caregivers.
Concerns with the DIR/Floortime model
Floortime may seem like an attractive treatment on the surface. For example, following a child’s lead rather than directing or controlling them as some perceive to be the case in applied-behavior-analytic based treatment may appear more progressive. However, inherent in the model are several concerns. First, Greenspan explicitly warns against rigidity and repetitive routines, instead encouraging variability of teacher behavior. For learners whose strengths are in creating and learning from routine, DIR/Floortime may be frustrating or confusing. Procedures such as those modeled by Dr. Greenspan in a video training series (Floortime DVD Training Guide) can also potentially cause greater levels of problem behavior or shape progressively lower levels of response effort in communication and in skills due to how those behaviors access reinforcement over time. Second, proponents of the DIR/Floortime model often cite the fact that they “follow the child’s lead” rather than require “compliance” to adult directions (Greenspan & Wieder, 2009). This is described as preferable because it allows for more creativity and flexibility on the part of the child and teacher. This lack of formal structure is reputed to be “good” for children, and in particular for children with ASD as it addresses their reported tendencies toward rigidity of routine. However, in a school, one of the most critical skills needed in a child’s repertoire is the ability to follow the direction (lead) of the teacher. Children who do not respond to the teacher’s directions and remain on their own agenda are unlikely to be successful in a classroom environment. To date no studies have shown a correlation between correct implementation of Floortime and success in a regular education setting. Third, the DIR/Floortime interaction style of following the child’s lead can result in the child practicing play skills that are non-functional and inappropriate. Dr. Greenspan in Engaging Autism repeats the mantra that “Floortime is not about doing the right or wrong thing,” “There is no right or wrong answer,” and “Vary what you do” (p 181-185). This approach is likely to interfere with any program that attempts to establish specific functional play skills.
What is the bottom line?
Currently, DIR/Floortime simply does not meet the basic standards of care for use as a treatment intervention. Specifically, there is little to no objective evidence of effectiveness. No one has demonstrated that results can be replicated across a range of children with ASD. And, no one has demonstrated reliable implementation of treatment procedures because treatment procedures are individualized based on the child’s behavior during treatment. Finally measurement of treatment effects has been limited to evaluations of DIR/Floortime procedures and effects on the DIR/Floortime created measures (Functional Emotional levels) rather than standardized assessments of development and language.
On the contrary, there is objective evidence of the effectiveness of EIBI (e.g., Lovaas 1993) that has been replicated across a wide range of children with ASD and can be reliably implemented while still individualized to the child’s specific needs. Because DIR/Floortime is a time consuming treatment (i.e., it is recommended that Floortime be implemented at least 20 hours a week), it may be detrimental to implement DIR/Floortime as a treatment for ASD as it greatly decreases the amount of time the child can be exposed to EIBI, a treatment that is empirically supported for ASD.
References
Dionne, M. & Martini, R. (2011) Floortime play with a child with autism: A single-subject study. Canadian Journal of Occupational Therapy, 78(3), 196-203.
Greenspan, S. I. & Wieder, S. (1997). Developmental patterns and outcomes in infants and children with disorders in relating and communicating: A chart review of 200 cases of children with autistic spectrum diagnoses. Journal of Developmental and Learning Disorders, 1, 87-141.
Greenspan, S. I. & Wieder, S. (1999). A functional developmental approach to autism spectrum disor-ders. The Journal of the Association for Persons with Severe Handicaps, 24(3), 147-161.
Greenspan, S. I. & Wieder, S. (2009). Engaging autism: Using the Floortime approach to help children relate, communicate, and think. Philadelphia, PA: A Merloyd Lawrence Book.
Hess, E. B. (2009). Floortime: A play intervention for children with autism. California APT Newsletter, 16-19.
Lovaas, O. I. (1993). The development of a treatment-research project for developmentally disabled and autistic children. Journal of Applied Behavior Analysis, 26(4), 617-630.
National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Educational Interventions for Children with Autism (2001). Educating children with autism. Washington, DC: National Academy Press.
Pajareya, K., & Nopmaneejumruslers, K. (2011). A pilot randomized controlled trial of DIR/FloortimeTM parent training intervention for pre-school children with autistic spectrum disorders. Autism, 15(5), 563-577.
Solomon, R., Nechels, J., Ferch, C., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The PLAY Project Home Consultation program. Autism, 11(3), 205-224.
Solomon, R., Van Egeren, L. A., Mahoney, G., Quon Huber, M. S., & Zimmerna, P. (2014). PLAY project home consultation intervention program for young children with autism spectrum disorders: A randomized controlled trial. Journal of Developmental Behavioral Pediatrics, 35(8), 475-485.
Wieder, S. & Greenspan, S. I. (2003) Climbing the symbolic ladder in the DIR model through floortime/interactive play. Autism, 7(4), 425-435.
Citation for this article:
Ross, R. K., Harrison K. L., & Zane, T. (2018). Focus on science: Is there science behind that?: Autism and Treatment with DIR/Floor Time. Science in Autism Treatment, 15(1), 20-24.
