Updated by:
Elizabeth Johnson Singh, MS, University of Oregon
Heidi Pattieshaw, BS, University of Oregon & Corvallis School District 509J

Description

Autism Treatments SummaryDIRFloortime (Developmental, Individual-differences, Relationship-based Floortime) is a child-centered, play-based intervention developed in the late 1990s by child psychiatrist Dr. Stanley Greenspan and clinical psychologist Dr. Serena Wieder. It is based on Greenspan’s theory of early emotional development, originally conceptualized in the mid-1980s (Greenspan & Wieder, 2006). The DIR framework emphasizes three core components: the child’s Developmental level, their Individual sensory and processing differences, and the importance of emotionally meaningful Relationships in supporting their growth. Today, the non-profit Interdisciplinary Council of Development and Learning (ICDL) oversees the dissemination of DIR and certification of Floortime trainers through online courses (ICDL, n.d.-a). The aim of Floortime is to foster reciprocal communication, emotional regulation, and flexible thinking in children with autism spectrum disorder (ASD) through child-led interactions with adults (Lal & Chhabria, 2013).

In practice, DIRFloortime sessions are typically delivered one-on-one in naturalistic environments, such as the home or classroom floor. A therapist or trained parent first assesses the characteristics of the child’s current state, including activity engagement, interests, and emotions. The adult then joins the child’s play, imitating or expanding on their actions and ideas while expressing interest and positive affect. The goal is to open and sustain closed “circles of communication” in which the adult approaches and the child responds (Mercer, 2015). For example, if a child rolls a toy car toward the adult, the adult might roll it back, smile, and comment on the action. The child then laughs and pushes the car again, completing another circle of back-and-forth engagement.

These exchanges are intended to help children regulate their bodies and attention, form secure relationships, and gradually develop more complex thinking and communication skills. A child might begin with simple, back-and-forth play routines and build toward joint problem-solving or expressing emotional ideas during play (Greenspan & Wieder, 2006). Proponents often recommend intensive treatment schedules of 15 or more hours per week of Floortime activities (Boshoff et al., 2020).

Research Summary

DIRFloortime has gained attention as a developmentally focused and relationship-based intervention, but the evidence base remains limited and mixed. Several studies and reviews have reported positive outcomes for children with ASD following participation in DIRFloortime programs, particularly in areas such as social-emotional development and parent-child bonding (Divya et al., 2023; Mercer, 2015; Pajareya & Nopmaneejumruslers, 2011; Solomon et al., 2007). For example, a small randomized controlled trial by Pajareya and Nopmaneejumruslers (2011) found that preschool-aged children whose parents were trained in Floortime techniques demonstrated more progress in emotional development than those in a control group over a 12-week period. Continued gains were observed in a one-year follow-up study (Pajareya & Nopmaneejumruslers, 2012). Divya et al. (2023) systematically reviewed 12 studies published between 2010 and 2020 and found overall improvements in communication, emotional functioning, adaptive skills, and parent reports of parent-child interaction. Reports of parent satisfaction with DIRFloortime have been consistently high (e.g., Solomon et al., 2007). Additionally, the developmental and relationship-based components of DIRFloortime are consistent with established thinking in developmental psychology about the importance of attachment and modeling emotional regulation to foster growth (Mercer, 2015).

Even with these encouraging results, multiple systematic literature reviews have concluded that there is currently insufficient support for the effectiveness of DIRFloortime compared to other treatments that have stronger evidentiary base (Boshoff et al., 2020; Divya et al., 2023; Mercer, 2015). The Divya et al. (2023) review noted that several of the included studies used quasi-experimental, correlational, or pre–post designs, with very few employing randomized controlled trials (RCTs). The authors also raised concerns about the generalizability of findings and noted that many studies lacked blind raters. Mercer (2015) analyzed ten outcome studies on DIRFloortime, all of which reported participant improvements. However, even the five RCTs included in this review contained design flaws and confounding variables, such as improvements potentially resulting from increased adult attention only or self-selection biases. Specifically, self-selection bias occurs when individuals who choose to participate differ from nonparticipants in ways related to the outcome, such as their motivation or engagement, making it difficult to attribute changes solely to the intervention (Biemer & Lyberg, 2010).

The Mercer (2015) review also noted a lack of consistency in assessment instruments across the studies and pointed out that very few studies have been replicated by independent research teams. Similarly, a systematic literature review of nine studies by Boshoff et al. (2020) found widespread methodological concerns, including failure to assess domains beyond social-emotional development, lack of randomization, selection bias, measurement bias, and high variability in study quality. Lack of randomization and selection bias go hand in hand; without random assignment, preexisting differences between participants can drive results rather than the intervention itself. Measurement bias also arises from a lack of standardization and occurs when researchers collect or score information inconsistently, resulting in data that give an inaccurate picture of a child’s progress. Together, these flaws make studies more vulnerable for alternative explanations of behavior change, making it difficult to credit outcomes directly to the intervention and raising questions about conflicts of interest. Additionally, the high variability in study quality makes it harder to compare findings and draw conclusions across the body of research. All three of these reviews unanimously concluded that further higher quality research is necessary to identify the actual effects of Floortime on children with ASD and advance the evidence base.

In the broader context of autism intervention research, large-scale reviews have found that developmental-only approaches, such as DIRFloortime, generally yield smaller effects than models that blend developmental principles with behavioral strategies. Sandbank et al. (2020), through Project AIM, a large-scale meta-analysis of over 150 early intervention studies, classified developmental-only interventions as producing small effect sizes across domains, including language and adaptive skills. That is, while some improvements were observed, they were relatively minor and may not have led to socially significant outcomes for children and families.

Moreover, task forces that evaluate treatments for people with autism do not endorse DIRFloortime as an emerging or established treatment for autism. The National Autism Center’s National Standards Project (Phase 2, 2015) concluded that DIRFloortime lacks the empirical support needed to meet criteria as an evidence-based practice. More recently, Hume et al. (2021) conducted a third-generation review of evidence-based practices for people with autism and excluded DIRFloortime from the list. This aligns with the findings of independent systematic reviews, which call for more rigorous, high-quality research before DIRFloortime can be recommended as a primary intervention.

Recommendations

DIRFloortime is not currently supported by sufficient high-quality research to be recognized as an established treatment for autism spectrum disorder by systematic reviews or task forces. While its emphasis on play-based engagement and individualized support may appeal to families and clinicians, there is not enough high-quality outcome data to support that it addresses the core characteristics of autism better than established treatments. Claims of efficacy should be interpreted with caution, and use of the intervention should be carefully monitored.

      • For Professionals: DIRFloortime should not be used as a standalone intervention. If implemented, it must be supplemented with treatments that are supported by strong empirical evidence. Professionals should inform caregivers about the limitations of the research base and use objective, validated tools to monitor outcomes.
      • For Caregivers: While DIRFloortime can be a way to support play and connection with your child, it should not take the place of therapies that are backed by strong research. It’s important to make sure your child’s treatment plan includes evidence-based interventions, such as Applied Behavior Analysis (ABA), the Early Start Denver Model (ESDM), or other Naturalistic Developmental Behavioral Interventions (NDBIs). These approaches blend developmental principles with behavioral teaching strategies and are often built into play and daily routines. For example, ABA might focus on breaking skills into smaller steps and celebrating progress, while ESDM uses playful interactions to build communication and social skills. NDBIs like Pivotal Response Training (PRT; Koegel & Koegel, 2006) or JASPER (Kasari et al., 2010) weave learning into natural activities, teaching things like turn-taking, joint attention, and language through play. If you’re considering DIRFloortime, you might want to ask providers how they plan to track your child’s progress, what tools they’ll use to measure growth, and how they’ll bring in proven practices alongside play-based interactions.
      • For Researchers: There is a clear need for well-designed, peer-reviewed studies evaluating DIRFloortime. Future research should include randomized controlled trials or single-case experimental designs with standardized measures, blind raters, appropriate control groups, and long-term follow-up in order to assess the true efficacy of this approach. There should also be more analyses isolating the effects of DIRFloortime when it is being used in conjunction with other therapies.

Despite the lack of evidence supporting the use of DIRFloortime, the ICDL maintains on its website that “DIRFloortime has the strongest research of any intervention to support its effectiveness in improving the core challenges of autism . . . [with] the highest levels of evidence” (ICDL, n.d.-b). These overstated claims should serve as a caution to clinicians and caregivers considering the therapy. While DIRFloortime is not associated with direct harm, there is still potential for indirect harm resulting from commitment to an ineffective treatment while rejecting interventions with stronger empirical support (Boshoff, 2020; Mercer, 2015). DIRFloortime’s emphasis on affect and individualization does not compensate for its lack of validated outcome data.

References

Systematic Reviews of Scientific Studies

Boshoff, K., Bowen, H., Paton, H., Cameron-Smith, S., Graetz, S., Young, A., & Lane, K. (2020). Child development outcomes of DIR/Floortime™-based programs: A systematic review. Canadian Journal of Occupational Therapy, 87(2), 153–164. https://doi.org/10.1177/0008417419899224

Divya, K. Y., Begum, F., John, S. E., & Francis, F. (2023). DIR/Floor time in engaging autism: A systematic review. Iranian Journal of Nursing and Midwifery Research, 28(2), 132–138. https://doi.org/10.4103/ijnmr.ijnmr_272_21

Mercer, J. (2015). Examining DIR/Floortime™ as a treatment for children with autism spectrum disorders: A review of research and theory. Research on Social Work Practice, 27(5), 625–635. https://doi.org/10.1177/1049731515583062

Sandbank, M., Bottema-Beutel, K., Crowley, S., Cassidy, M., Dunham, K., Feldman, J. I., … & Woynaroski, T. (2020). Project AIM: Autism intervention meta-analysis for studies of young children. Psychological Bulletin, 146(1), 1–29. https://doi.org/10.1037/bul0000215

Selected Scientific Studies

Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled caregiver-mediated joint engagement intervention for toddlers with autism. Journal of Autism and Developmental Disorders, 40(9), 1045–1056. https://doi.org/10.1007/s10803-010-0955-5

Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication, social, and academic development. Paul H. Brookes Publishing.

Pajareya, K., & Nopmaneejumruslers, K. (2011). A pilot randomized controlled trial of DIR/Floortime™ parent training intervention for preschool children with autistic spectrum disorders. Autism, 15(5), 563–577. https://doi.org/10.1177/1362361310386502

Pajareya, K., & Nopmaneejumruslers, K. (2012). A one-year prospective follow-up study of a DIR/Floortime® parent training intervention for preschool children with autistic spectrum disorders. Journal of the Medical Association of Thailand, 95(9), 1184–1190.

Solomon, R., Necheles, 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. https://doi.org/10.1177/1362361307076842

Task Force Reports and Position Statements

Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yucesoy-Ozkan, S., & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders, 1–20. https://doi.org/10.1007/s10803-020-04844-2

National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. https://nationalautismcenter.org/national-standards/phase-2-2015/.

Other References

Biemer, P. P., & Lyberg, L. E. (2010). Self-selection bias. In Encyclopedia of Survey Research Methods. Sage Publications. Retrieved from https://methods.sagepub.com/ency/edvol/encyclopedia-of-survey-research-methods/chpt/selfselection-bias

Greenspan, S. I., & Wieder, S. (2006). Engaging autism: Using the Floortime approach to help children relate, communicate, and think. Da Capo Lifelong Books. https://books.google.com/books?id=1yUqcJzopjAC

Interdisciplinary Council on Development and Learning. (n.d.). DIRFloortime®. https://www.icdl.com/dir

Interdisciplinary Council on Development and Learning. (n.d.). DIRFloortime® research, science, and evidence-base. https://www.icdl.com/research

Lal, R., & Chhabria, R. (2013). Early intervention of autism: A case for Floor Time approach. In M. Fitzgerald (Ed.), Recent Advances in Autism Spectrum Disorders (Vol. 1). InTechOpen. https://doi.org/10.5772/54378

Ross, R. K., Harrison K. L., & Zane, T. (2018). Is there science behind that?: Autism and Treatment with DIR/Floor Time. Science in Autism Treatment, 15(1), 20-24.

Reference for this article:

Singh, E. J., & Pattieshaw, H. (2025). A treatment summary of DIRFloortime. Science in Autism Treatment, 22(12).

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