The Use of the Developmental, IndividualDifference, RelationshipBased DIRFloortime approach for Work

1
The Use of the Developmental, Individual-Differen
ce, Relationship-Based (DIR-Floortime) approach
for Working with Children with Autism

• Presented by
• Melissa Howlett
• Nicole Crane
• Jennifer Tangeman
• Sue McHugh
• Caldwell College
• July 27, 2006

2
Stanley Greenspan, M.D.

• B.A. Harvard / Yale Med School
• In 1975, he became founding president of ZERO TO
  THREE National Center for Infants, Toddlers, and
  Families.
• Zero to Three Video http//www.zerotothree.org/zt
  t_aboutus.html
• Chairman of the Interdisciplinary Council on
  Developmental and Learning Disorders
• http//www.icdl.com/
• Currently a Clinical Professor of Psychiatry,
  Behavioral Sciences, and Pediatrics at George
  Washington University Medical School

3
Stanley Greenspan, M.D.

• Greenspan has written over 40 books
• The Course of Life Psychoanalytic Contributions
  to Understanding Personality Development (1980)
• Playground Politics (1993)
• Engaging Autism (2006)
• He is Currently the supervising Child
  Psychoanalyst at the Washington Psychoanalytic
  Institute

4
Serena Wieder, Ph.D.

• Her degree is in clinical psychology
• In working with Stanley Greenspan, M.D., they
  developed the DIR/Floortime Approach and founded
  the Interdisciplinary Council on Developmental
  and Learning Disorders (ICDL).
• Together Wieder and Greenspan wrote a few books
  and made a video series on Floor Time for
  Children with Special Needs. They also have a
  web-radio program.
• Wieder is one of the founders of the Floortime
  Foundation.

5
Psychoanalysis?

• Relational psychoanalysts argue that motivation
  emerges out of relationships
• Motivations are partly structured by my
  interactions with others
• Desires and urges cannot be separated from the
  relational contexts in which they arise

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Psychoanalysis? (contd.)

• This does not mean that motivation is determined
  by the environment (i.e., behaviorism) but that
  motivation is determined by the systemic
  interaction of a person and their environment.
• Relational psychoanalysis is closely allied with
  social constructionism ( i.e, all knowledge is
  derived from and maintained by social
  interactions)

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History

• Philosophically, relational psychoanalysis is
  closely allied with social constructionism.
• Social constructionism is a sociological theory
  of knowledge developed by Berger and Luckmann
  with their 1966 book, The Social Construction of
  Reality.
• Berger and Luckmann argue that all knowledge is
  derived from and maintained by social
  interactions.
• When people interact, they do so with the
  understanding that their respective perceptions
  of reality are related, and as they act upon this
  understanding their common knowledge of reality
  becomes reinforced. Since this common sense
  knowledge is negotiated by people, human
  typifications, significations and institutions
  come to be presented as part of an objective
  reality. It is in this sense that it can be said
  that reality is socially constructed

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Premise Behind The DIR/Floortime Approach

• The basic premise behind DIR is that children
  learn skills from the relationships which they
  have with their caregivers.
• It was developed in response to the needs of the
  increasing population diagnosed with disorders on
  the Autistic Spectrum, who were then being either
  served by behavioural methods or cognitive
  skills, and other impairments of development and
  learning.

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DIR Model

• Beginning in the 1980s Greenspan built upon
  research into social-emotional development to
  create a proprietary intervention for children
  with deficits in relating and communicating. This
  method is known as Developmental Individual
  Difference Relationship Model

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What is the DIR Approach?

• DIR is an approach that focuses on the total
  child, most especially their ability to interact
  with others.

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What is DIR?

• D is for developmental
• Understanding where a child is developmentally
  is key to planning a treatment program
• 6 developmental milestones that every child must
  master

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What is DIR?

• I is for individual differences
• How the child (especially with disabilities)
  responds to the world around them
• Many children face biological challenges

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What is DIR?

• R is for Relationship based
• Children must build relationships with care
  givers to return to a healthy developmental path

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Six Developmental Milestones

• These are identified as the 6 basic steps that
  all children go through
• Floortime identifies these steps as a foundation
  for all learning and development

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Milestone 1 Self Regulation and Interest in
the world

• Children learn self calming
• Children learn to regulate themselves
• through their sensory systems

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Milestone 2 Intimacy

• Initially with primary caregiver, then
  
• with future relationships
• Mastery of this milestone is needed for
• future motor, cognitive and language
• skills

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Milestone 3 Two Way Communication

• Beginning of communication
• Infants interact with parents
• Two way communication is essential for all
  human interaction

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Milestone 4 Complex Communication

• Multiple gestures use for communication
• Builds a childs motor and motor planning
  skills

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Milestone 5 Emotional

• Expanded use of words
• Putting words to intentions, wishes
• and feelings

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Milestone 6 Emotional Thinking

• Ideas and words are put into logical
• sequences
• Child is able to express wide range of
  emotions in play

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Individual Differences

• Floortime is individualized for each child.
  Children might have biological difficulties that
  interfere with their ability to learn.

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Individual Differences

• Difficulty with Sensory Reactivity
• Difficulty receiving information through senses
• (Child may be overactive or under reactive)

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Individual Differences

• Processing Difficulties
• Children may have difficulties
• processing information because of
• difficulties with sensory

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Individual Differences

• Motor Planning Difficulties
• Children with disabilities may have low
• muscle tone. This makes motor planning
  difficult.
• Poor motor planning makes even the
  simplest tasks difficult ( i.e. eating)

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Relationship Base

• The childs developmental challenges and
  individual differences affect how they relate to
  others
• Approach assists caregivers in developing
• relationships with child
• Emotionally based interactions are an
• important part of the approach

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Floortime

• Floor time is a systematic developmental
  
• approach
• Works on the 6 Milestones
• Works to help a child acquire skills they are
  
• missing
• Floortime in a 20 30 minute period of
• interaction and play

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Floortime

• Floortime is child initiated play
• Floortime follows a childs lead in what
  interests them
• Floortime encourages a child to interact with
  you
• Floortime enables your child to master the
  emotion milestones one by one

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Strategies for Floortime

• Help your child do what they want
• Interact at all times
• Follow the childs lead
• Join in repetitive play
• Insist on a response
• Position yourself in front of the child

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Floor Time Tuning In To Each ChildBased on the
work of Stanley Greenspan, M.D.For Early
Childhood Staff Development and Parent Education
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Floortime Goals(The Floortime Foundation,
www.floortime.org)

• There are 4 main goals of floortime that will
  help a child master specific milestones.
• Goal 1 Encourage attention and intimacy.
• As a child is able to remain calm while
  exploring the environment around him or her, the
  main goal is to get him or her to engage with you
  and take advantage of your presence.
• Goal 2 Two-way communication. This involves
  initially getting the child to communicate
  his/her wishes, needs, and intentions without the
  use of words by using facial expressions, eye
  contact, and hand/body movement, which promotes
  interaction, logic and problem solving.

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Floortime Goals (contd.)

• Goal 3 - Encourage the use of feelings and
  ideas.
• The child learns to express his/her feelings or
  intentions using words and through pretend play.
  Dramatic and make-believe play is used to help
  the child verbally express his/her needs, wishes,
  and feelings.
• Goal 4 Logical thought.
• Help the child make a connection between his/her
  ideas and feelings to come to the world around
  him or her. A logical understanding of the world
  develops.

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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
(Greenspan Wieder, 1997) 

• PURPOSE
• To reveal patterns in presenting symptoms,
  underlying processing difficulties, early
  development, and response to intervention in
  order to generate hypotheses for future studies

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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
(Greenspan Wieder, 1997)

• PROCEDURE
• Reviewed charts of 200 children meeting the
  criteria for Autism or PDD-NOS.
• Conducted in a private practice setting with
  college educated families. 
• Scored 30 to 52 in the autistic range on the
  Childhood Autism Rating Scale
• Subjects participated in evaluations and
  interventions for two or more years
• Comprehensive diagnostic workup
• Intervention program based on individual needs
• Reevaluation every 2 to 6 months
• Each child followed for at least 2 years, some up
  to 8 years
• Age Range 22 months to 4 years
• (Majority 2 ½ to 3 ½ years at initial
  evaluation)
• All children in the study received 2 to 5 hours
  of Floor Time in the home. These children also
  received comprehensive services such as speech
  therapy, occupational therapy, special or general
  education services

34
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
(Greenspan Wieder, 1997)

• Initial Visit Review
• presenting symptoms and problems
• prior developmental history
• the childs maturational and constitutional
  patterns (individual differences)
• observations of the infant/child and
  infant/child-parent interaction patterns
  (including videotapes of these and, where
  possible, family videotapes of early
  developmental patterns)
• family history
• family functioning 
• the Childhood Autism Rating Scale (CARS) (Western
  Psychology Services, 1988), which rates the
  severity of autistic symptoms, was implemented
  for the initial presenting symptoms and
  developmental patterns and at the last follow-up
  visit.

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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
(Greenspan Wieder, 1997)

• FOLLOW-UP VISITS
• parental reports of changes since the last
  evaluation
• adaptive and developmental patterns
• observations of parent-child interactions
• reevaluation reports
• The Functional Emotional Assessment Scale (FEAS)
• Vineland Adaptive Behavior Scale
• sample of children who had done exceedingly well

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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
(Greenspan Wieder, 1997)

• RESULTS
• 200 children with ASD received the DIR approach
  (Greenspan
• Wieder, 1997 Greenspan Wieder, 1999)
• Over half the children had good to outstanding
  outcomes on the Functional Emotional Assessment
  Scale (high levels of language, creative and
  reflective thinking, and social interaction).
• A more in-depth examination of 20 of the highest
  functioning children detailed marked gains on the
  Vineland Adaptive Behavior Scales (Sparrow,
  Balla, Cicchetti, 1984) and the CARS (an autism
  rating scale) (Schopler, Reichler, Renner,
  1988)

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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
(Greenspan Wieder, 1997)

• RESULTS
• 58 of participants made good to outstanding
  progress
• GOOD TO OUTSTANDING GROUP
• Improved in affect, social behavior, cognitive
  skills, symbolic play, creative behavior
• No longer engaged in avoidant, self-stimulatory,
  or perseverative behavior
• No longer considered autistic according to the
  Childhood Autism Rating Scale (CARS)

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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
(Greenspan Wieder, 1997)

• RESULTS
• 25 of children made medium progress
• MEDIUM GROUP
• Gestural communication
• Significant delays in symbolic language and play
  still present
• No longer engaged in self-stimulatory, avoidant,
  perseverative behavior

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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
(Greenspan Wieder, 1997)

• RESULTS
• 17 of children had ongoing difficulties
• ONGOING DIFFICULTY GROUP
• Little or no improvement in affect, symbolic
  ability, attention, or avoidant behavior
• Presented more extreme autistic symptoms than
  when first evaluated

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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
(Greenspan Wieder, 1997)

• LIMITATIONS
• Chart review approach
• The evaluation settings varied
• In-depth observation of interactions with a
  trusted and known caregiver with whom they can
  share their best gestural and communication,
  complex interactive capacities.
• Many parents, when asked, were quite concerned
  that their childs relationship capacity was
  being diagnosed without being observed. 
• Sample limitations
• results only apply to children in study
• More research (Clinical Trial)
• larger, more diverse population
• researchers outside of the creators of Floortime

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Can Children with Autism Master the Core Deficits
and Become Empathetic, Creative, and Reflective?
A Ten to Fifteen Year Follow-Up of a Subgroup of
Children with Autism Spectrum Disorders Who
Received a Comprehensive Developmental,
Individual-Difference, Relationship-Based (DIR)
Approach (Wieder Greenspan, 2005)

• PURPOSE To determine the longitudinal effects
  of the DIR approach for 16 children with autism
  ten to fifteen years after treatment.
• Note- this study starts out with a disclaimer,
  This report is not intended to be an outcome
  study of the DIR/Floortime model, but only to
  answer the specific question raised above.
  However, in the Discussion/Conclusion section of
  this article the positive long-term progress of
  the 16 students that participated in this study
  was attributed to the DIR intervention these
  children received during their early years.

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Can Children with Autism Master the Core Deficits
and Become Empathetic, Creative, and Reflective?
(Wieder Greenspan, 2005)

• PROCEDURE
• Parents were asked to answer questions on the
  Functional Emotional Developmental Questionnaire
  regarding regulation and shared attention,
  engagement, two-way intentional affective
  signaling and communication, social problem
  solving, creating symbols and ideas, and higher
  order thinking.
• Through the use of videotapes, verbal interviews,
  and recordings clinicians rated the same children
  by using similar rating scales. Additionally,
  the clinicians rated the level of empathy,
  creativity, and talent.
• School and cognitive reports were also obtained.
• Parents also completed the Achenbach Scales
  (CBCL) to obtain an independent measure of
  functioning in regard to social competence,
  activities, school, anxiety/depression,
  withdrawal/depression, somatic complaints, social
  problems, thought problems, attention problems,
  rule breaking behavior, aggressive behavior, and
  other problems.
• Motor tone, motor planning, and sensory
  reactivity were also examined by having parents
  provide input on the Sensory Motor Questionnaire.
  

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Can Children with Autism Master the Core Deficits
and Become Empathetic, Creative, and Reflective?
(Wieder Greenspan, 2005)

• RESULTS
• Showed that with the DIR/Floortime approach 16
  children with autism progressed out of their core
  symptoms and deficits, becoming empathetic,
  creative, and reflective with healthy peer
  relationships and solid academic skills.
• In comparison to typically developing peers, they
  demonstrated the same incidence of mental health
  problems.
• Some sensory challenges remained evident, but did
  not impede their ability to relate, communicate,
  and think.

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Can Children with Autism Master the Core Deficits
and Become Empathetic, Creative, and Reflective?
(Wieder Greenspan, 2005)

• Claims/Acknowledgments
• Intensive DIR model intervention during the early
  years of development resulted in these children
  becoming empathetic, creative, and reflective,
  with healthy peer relationships and good academic
  performances.
• DIR model encourages engagement, symbolic play,
  higher order thinking, ongoing problem solving,
  reality based logical conversations, play dates,
  and friendships.

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Limitations of this Study

• Only questionnaires were used to gather data.
  Information provided in parent questionnaires is
  subjective and may be biased.
• No formal testing or means of measurement were
  used.
• This study states, we dont know how
  representational this population of children with
  ASD is and how many others share characteristics
  of this group.

46
Greenspan's Definition's

• Developmental, Individual-Difference,
  Relationship-Based (DIR) also known as
  DIR/Floortime A model of addressing a childs
  developmental challenges through relationship and
  affect, focusing on the childs individual
  differences, and developmental levels (a childs
  ability to stay engaged, express mutual pleasure
  and attention, to engage in complex problem
  solving and symbolic play, and to link ideas).
  The cornerstone of the DIR model is Floortime.
• A warm, intimate way of relating to children. A
  DIR/Floortime philosophy means engaging,
  respecting, and getting in tune with children in
  order to help them elaborate through gestures,
  words, and pretend play what is on their minds.
  DIR/Floortime is a process that can be used to
  help support childrens emotional and social
  development
• Behavioral Interventions These are interventions
  based on operant conditioning theories which
  focus on modifying a behavior through reinforcing
  specific goal behaviors. The emphasis is on
  discrete behaviors rather than underlying
  developmental processes or foundations. The most
  widely used version of behavioral intervention is
  the ABA discrete trial approach. A more recently
  developed behavioral intervention is Pivotal
  Response Training, focusing more on incidental
  learning.

47
Claims of MSNBC research, National Research
Council, Cure Autism Now

• Focuses on the developmental processes leading to
  relating, communicating, and thinking (Wieder
  Greenspan, 2005).
• The Floortime Foundation claims that in a review
  of 200 children diagnosed with autistic spectrum
  disorders who were treated intensively with DIR
  Floortime for up to six years, more than 50
  percent have "become warm, engaged and loving."
• Some critics say there is not enough scientific
  research supporting the effectiveness of DIR
  Floortime and that children with more severe
  autism may not be well-served by such a
  child-centered program.

48
FACTS The Newsletter of LEARNS, The Statewide
Systems Change Initiative for Inclusive
EducationLearns/Greenspan Interview (2004)

• L ABA, particularly discrete trial training, is
  very popular these days. One of the reasons may
  be that it has clearly defined goals and
  directions. Many practitioners seem to have
  difficulty with the fuzziness or inherent
  unpredictability of a technique such as DIR, in
  which you follow the childs lead.
• (Greenspan agrees with this challenge)
• Greenspan states there are 2 things we should
  know
• Lovaas 87 study-not a random assignment
• Lovaas 87 study-did not measure social/emotional
  outcomes

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FACTS The Newsletter of LEARNS, The Statewide
Systems Change Initiative for Inclusive
Education The University of Maine Center for
Community Inclusion and Disability
Studieshttp//www.ccids.umaine.edu/Learns/Green
span Interview (2004)

• L Is research going to be done to backup DIR?
• G The DIR staff, along with Tristam Smith who
  worked closely w/ Lovaas are putting grants in to
  begin research.
• Grant in Federal Government
• Foundation boards to do pilot studies
• not easy

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The PLAY Projecthttp//www.medicineatmichigan.org
/magazine/2002/fall/autism/default.asp
Rick Solomon and Katie Goren

• The bond between parent and child can be used to
  bring children through a once-hidden doorway and
  into the warmth of a relationship.
• 50 -improve significantly
• 25-exhibit moderate improvement
• 25-(usually children with physical or
  developmental problems) see little improvement.
• The PLAY Project is a wonderful model for
  understanding, assessing and intervening with
  complex developmental problems.
• Ive known Rick Solomon for many years and hes
  not only a pioneer and leader in Michigan, but
  also one of a small group of clinicians and
  researchers who are transforming the way we care
  for infants and young children and families with
  various challenges throughout the world.
• -Stanley Greenspan, M.D.
•  

51
A Tale of Two SchoolsTime MagazineMay 7, 2006

• School 1 Alpine Learning Group (Paramus, NJ)
• Robotic behavior, lack of emotion and inability
  to use trained skills outside school are some of
  the shortcomings critics attribute to ABA
• "Anything outside ABA is basically experimental
  at this point."
• -Tristam Smith, University of Rochester
• School 2 Celebrate the Children (Stanhope, NJ)
• Floortime
• emotional connection even with the most
  withdrawn child
• Reports the absence of controlled, randomized
  studies
• Greenspan has begun a series of studies at York
  University in Toronto
• imaging studies that will compare the brains of
  DIR kids with those treated with ABA.
• Remarks in response to TIME article
• Kelly Crosby Rochester, New York, U.S.
• Special Education Teacher
• Bridget A. Taylor, Psy.D., B.C.B.A. Executive
  Director Alpine Learning Group Paramus, New
  Jersey

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Shortcomings/Criticisms of DIR(Corsello, 2005)

• The effectiveness of DIR in treating children
  with autism is based strictly on theories.
• No scientific research using controlled studies
  is available to support its effectiveness. No
  peer reviewed research exists.
• This method of intervention is highly dependent
  on the skills of the person (parent or
  professional) that is implementing the program.
• The person implementing the program has to
  recognize when and how to respond to a childs
  behaviors, as there are no set patterns of
  responses and adult-initiated teaching trials.

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Resources

• http//www.stanleygreenspan.com/
• http//www.icdl.com/
• www.floortime.org.
• http//www.med.umich.edu/opm/newspage/2003/play.ht
  m
• WEB-BASED RADIO SHOW WITH STANLEY I. GREENSPAN,
  M.D.TUNE IN THURSDAYS FROM 1030 TO 1130 a.m.
  EST

54
The Boy Who Loved Windowsby Patricia Stacey

• Opening Walkers heart and mind
• In The Boy Who Loved Windows, Patricia Stacey
  tells the story of how her son was saved from a
  path leading to autistic isolation.

55
The Child with Special NeedsStanley I.
Greenspan, M.D.Serena Wieder, PH.D.
56
Engaging AutismStanley I. Greenspan, Serena
Wieder, PH.D.
57
New York State Department of Health Early
Intervention Program (1999). Clinical Practice
Guideline Report of the Recommendations
Autism/Pervasive Developmental Disorders,
Assessment and Intervention for Young Children
(Age 0-3 Years). Albany, NY.

• RECOMMENDATIONS
• Defined Treatment goals/objectives
• Baseline/Ongoing Assessment of progress
• Modifications of treatment plan
• Coordinate with other interventions
• In choosing this program (DIR), remember
• No adequate research
• Interference with behavioral/educational program
• Time-Intensive

58
Questions
59
References

• Corsello, C.M. (2005). Early intervention in
  autism. Infants and Young Children, 18, 74-85.
• 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.
• New York State Department of Health Early
  Intervention Program (1999). Clinical Practice
  Guideline Report of the Recommendations
  Autism/Pervasive Developmental Disorders,
  Assessment and Intervention for Young Children
  (Age 0-3 Years). Albany, NY.
• Western Psychology Services (1988). Childhood
  Autism Rating Scale (CARS). Los Angeles, CA.
• Wieder, S. Greenspan, S. (2005). Can children
  with autism master the core deficits and become
  empathetic, creative, and reflective? The
  Journal of Developmental and Learning Disorders,
  9, 39-61.
• http//www.ccids.umaine.edu/
• http//www.floortime.org
• http//www.medicineatmichigan.org/
• http//www.serenawieder.com/