EvidenceBasefortheDIRModel_Cullinane090109

8/13/2019 EvidenceBasefortheDIRModel_Cullinane090109

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Evidence Base for the DIR/Floortime Approach

Executive Summary

The folloin! article provides support of DIR/Floortime as an "evidence#$asedpractice%& The challen!es to measurin! effectiveness of the approach for children ithautism include the tar!ets of the intervention' hich are core deficits or underlyin!capacities' rather than isolated $ehaviors' and the diversity of the population ith adia!nosis of autism% Research has focused on the three ma(or aspects of DIR' i%e%'Developmental frameor)' Individual Differences' and Relationship#$ased intervention%*utstandin! research in each area is hi!hli!hted% In addition' an area of research hasfocused specifically on the inte!rative aspects of D' I' and R and the investi!ation ofcomplex systems% *n#!oin! studies are evaluatin! the effects of intensive DIR therapyon overall $rain function% The article also summari+es critical revies of all research inthe field for $oth ABA and DIR/FT approaches' and current recommendations forfuture research paradi!ms% In addition to research' the article also cites current clinical

use and acceptance of DIR/Floortime $y ma(or or!ani+ations% In conclusion'DIR/Floortime has a solid foundation of research and clinical experience support' andcan $e considered $oth "evidence#$ased& and also a prominent therapeutic option forchildren ith disorders of relatin! and communicatin!%

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Evidence Base for the DIR/Floortime Approach8-31-09

Diane -ullinane' .%D%' FAADiplomat' American Board of ediatrics

Diplomat in Developmental#Behavioral ediatricsDiplomat in 0eurodevelopmental Disa$ilities

Faculty' Interdisciplinary -ouncil on Development and 1earnin! Disorders

Due to the recent $ud!et cuts in -alifornia' the 2evidence3 to (ustify pu$lic fundin! forDIR/FT pro!rams is currently under scrutiny $y re!ional centers in -alifornia% Thisarticle attempts to summari+e the most current research evidence pertainin! to the DIR/FT approach' hich ill not only provide sufficient $asis for a determination thatDIRFT is evidence#$ased $ut ill also present an historical vie that shos that thefield of intervention for children ith DD is shiftin! from more $ehavioral approachestoards more developmental models overall%

From Trailer bill: Evidence-based practice means a decision making process wic

integrates te best available scienti!icall" rigoro#s researc$ clinical e%pertise$ and

individ#al&s caracteristics' Evidence-based practice is an approac to treatment ratertan a speci!ic treatment' Evidence-based practice promotes te collection$

interpretation$ integration$ and contin#o#s eval#ation o! valid$ important$ and applicable

individ#al- or !amil"-reported$ clinicall"-observed$ and researc-s#pported evidence'

Te best available evidence$ matced to in!ant or toddler circ#mstances and pre!erences$is applied to ens#re te (#alit" o! clinical )#dgments and !acilitates te most cost-

e!!ective care'

What to measure?A startin! point to measure effectiveness of intervention is to determine the factors to $emeasured% This is a ma(or challen!e in the field of developmental disa$ilities% 4enerally'$ehavioral approaches measure specific tar!eted $ehaviors% .ore recently' there has $eena focus on measurin! spontaneous interactions and !enerali+ation of s)ills' hichpresents ne challen!es in measurement% Also' developmental pro!rams tar!etunderlyin! capacities' or 2core deficits3 as the focus of intervention' ith pro!ress evidentin a complex array of chan!es in interactive $ehavioral patterns%

*evelopmental approaces seek to meas#re canges in an individ#al&s capacit" !or:

+ared attention

,bilit" to !orm warm intimate and tr#sting relationsips

Te abilit" to initiaterater tan respond. #sing intent!#l actions and social

engagement/ spontaneo#s comm#nication

Te abilit" to participate in reciprocal two-wa"$ m#t#al. interactions wile in a

range o! di!!erent emotional states

roblem solving tro#g a process o! co-reg#lation$ reading$ responding and

adapting to te !eelings o! oters

reativit"

Tinking logicall" abo#t motivations and perspective o! oters

*eveloping an internal personal set o! val#es

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These developmental measures are more closely ali!ned to the dia!nostic criteria forDD/autism than the older ABA measures such as I6' performance on early academics)ills and responsive $ehaviors% The 0ational Research -ouncil stated in 577,8 ".oreappropriate outcome measures are improvement in initiation of spontaneouscommunication in functional activities' and !enerali+ation of lan!ua!e across activitiespeople' and settin!s&

1ord' -atherine9 .c4ee' :ames ;Editors' evidence first shoed the promise of the DIR/FT approach8-harts of 577 children ho ere dia!nosed ith autistic spectrum disorder ererevieed% The !oal of the revie as to reveal patterns in presentin! symptoms'underlyin! processin! difficulties' early development and response to intervention inorder to !enerate hypotheses for future studies% The chart revie su!!ests that a num$er

of children ith autistic spectrum dia!noses are' ith an appropriate interventionpro!ram' capa$le of empathy' affective reciprocity' creative thin)in!' and healthy peerrelationships9 that an intervention approach that focuses on individual differences'developmental level' and affective interaction may $e especially promisin!9

4reenspan' S%I% and =ieder' S% ;,>< Developmental patterns and outcomes in infants and children ithdisorders in relatin! and communicatin!8 A chart revie of 577 cases of children ith autistic spectrumdia!noses% :ournal of Developmental and 1earnin! Disorders ,8C>#,,%
http://www.amazon.com/gp/redirect.html?ie=UTF8&location=http%3A//www.amazon.com/Child-Special-Needs-Encouraging-Intellectual/dp/0201407264?ie=UTF8&s=books&qid=1173321486&sr=1-1&tag=i0e9-20&linkCode=ur2&camp=1789&creative=9325%22%3EChild%20with%20Special%20Needs%3C/a%3E%3Cimg%20src=%22http%3A//www.assoc-amazon.com/e/ir?t=i0e9-20&l=ur2&o=1%22%20width=%221%22%20height=%221%22%20border=%220%22%20alt=%22%22%20style=%22border%3Anone%20!important;%20margin%3A0px%20!important;%22%20/%3Ehttp://www.amazon.com/gp/redirect.html?ie=UTF8&location=http%3A//www.amazon.com/Child-Special-Needs-Encouraging-Intellectual/dp/0201407264?ie=UTF8&s=books&qid=1173321486&sr=1-1&tag=i0e9-20&linkCode=ur2&camp=1789&creative=9325%22%3EChild%20with%20Special%20Needs%3C/a%3E%3Cimg%20src=%22http%3A//www.assoc-amazon.com/e/ir?t=i0e9-20&l=ur2&o=1%22%20width=%221%22%20height=%221%22%20border=%220%22%20alt=%22%22%20style=%22border%3Anone%20!important;%20margin%3A0px%20!important;%22%20/%3Ehttp://www.amazon.com/gp/redirect.html?ie=UTF8&location=http%3A//www.amazon.com/Child-Special-Needs-Encouraging-Intellectual/dp/0201407264?ie=UTF8&s=books&qid=1173321486&sr=1-1&tag=i0e9-20&linkCode=ur2&camp=1789&creative=9325%22%3EChild%20with%20Special%20Needs%3C/a%3E%3Cimg%20src=%22http%3A//www.assoc-amazon.com/e/ir?t=i0e9-20&l=ur2&o=1%22%20width=%221%22%20height=%221%22%20border=%220%22%20alt=%22%22%20style=%22border%3Anone%20!important;%20margin%3A0px%20!important;%22%20/%3E


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The DIR/FT has provided a developmental frameor) that has $een studied and foundto $e accurate and effective in understandin! $ehavior% The idely used2a"le" +cales o!n!ant developmenthas adopted the DIR milestones as the measure of social#emotionaldevelopment throu!h a process of careful standardi+ation across populations%

The folloin! research studies report the effectiveness of developmental approach8

Ro!ers' S% and D% Delalla% ;,,%

:ocelyn' 1%' et al% ;,C


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The 0ational Research -ouncil of the 0ational Academy of Sciences' in their 577,landmar) report' "Educatin! -hildren ith Autism'& called for tailorin! the treatmentapproach to the uni?ue features of the individual child%

1ord' -atherine9 .c4ee' :ames ;Editors


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.ahoney' 4% erales' F% ;577#CJ%

im' :% and .ahoney' 4% ;577J#,7%

4erns$acher has shon that intervention can chan!e the ay parents interact to increasereciprocity and that these chan!es are correlated ith chan!es in social en!a!ement andin lan!ua!e%

4erns$acher .%A%' ;577


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Claims and Current ResearchBehavioral approaches' specifically ABA have made seepin! claims a$out theireffectiveness% In 577,' The 0ational Academy of Sciences report concluded that there issome evidence for $oth developmental approaches and $ehavioral approaches $ut nodefinitive evidence for either% There have $een no comparative studies $eteen these toapproaches%

1ord' -atherine9 .c4ee' :ames ;Editors' pp C#C

Dre 5775' and .ahoney 577 have su!!ested that other methodolo!y $e considered inlieu of randomi+ed controlled trials' such as norm referenced scores' and lo!ic models%

Dre' A%' et al% ;57755%

.ahoney' 4% and erales' F% ;577


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Dr% Doreen 4ranpeesheh' ho serves as a First @ice -hair of the Autism Society ofAmerica' has ritten extensively on ABA% She runs a lar!e company devoted to ABAcalled the -enter for Autism and Related Disorders ;-ARD'Te

remarkable eterogeneit" displa"ed b" people wit a#tism calls into (#estion te idea

tat randomi?ed clinical trials Ts. so#ld$ at te time o! te development o! te !ield$be considered te gold standard !or eval#ation weter a speci!ic treatment as merit'

-arr' E%' 4ranpeesheh' D%' 4rossman' 1% The Future of Applied Behavior Analysis in Autism SpectrumDisorder% Autism Advocate 577C9 8J7#JC%

Historically' $ehavioral approaches have not focused on relationships or individualdifferences% ivotal Response Trainin! or RT a form of naturalistic $ehavioral treatmentis a more recent form of $ehavioral intervention that is $ased on folloin! the child3sinterest to increase motivation%

oe!el' R%' oe!el' 1%' and .c0erney' E% ;577,/J/eCJon pa!e

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http://pediatrics.aappublications.org/cgi/reprint/107/5/e85http://pediatrics.aappublications.org/cgi/reprint/107/5/e85http://pediatrics.aappublications.org/cgi/reprint/107/5/e85http://pediatrics.aappublications.org/cgi/reprint/107/5/e85


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Easter Seals Easter Seals funds in home pro!rams' usin! Floortime' in many sites acrossthe country' includin! central -A' Fresno -ounty%%easterseals%com/site/a!eServerKpa!enameMntlcCNautismNserviceNpreschoolhttp8//centralcal%easterseals%com/site/a!eServerKpa!enameM-A-0NSNplaypro(ect

Autism Spea)s refers to DIR/Floortimehttp8//%autismspea)s%or!/hattodo/index%php

The -enter for Disease -ontrol also lists DIR/Floortime as a ma(or treatment approach%%cdc%!ov/nc$ddd/autism/treatment%htm

The Institute for -hildren ith Developmental and 1earnin! disorders ;I-D1< provides atrainin! pro!ram for clinicians and teachers to $ecome certified in usin! DIR/FT% Thecertification process re?uires several years of trainin!' and is desi!ned for licensed orcertificated clinicians and teachers% Floortime can also $e done $y parents' care!ivers'and non#certified professionals' under the !uidance of a specialist for a particular child% Itis utili+ed in over CJ countries around the orld%

In -alifornia' DIR/FT pro!rams currently receive fundin! throu!h many re!ionalcenters includin! those in San Die!o' *ran!e -ounty' !reater 1os An!eles area' SantaBar$ara' San Francisco and the Bay area%

ConclusionEfforts continue to understand the complex disorder of autism% =e are all aare of thealarmin! increase in incidence' and the lac) of specific information a$out etiolo!y%Fortunately there is a !roin! understandin! of individual differences' the importance ofrelationship $ased intervention' and the capacity of children to improve%

4reenspan' S%I% and =ieder' S% ;577J< -an -hildren ith Autism .aster the -ore Deficits and BecomeEmpathetic' -reative and ReflectiveK A Ten to Fifteen Gear Follo#up of a Su$!roup of -hildren ithAutism Spectrum Disorders ;ASD< =ho Received a -omprehensive Developmental' Individual#

Difference' Relationship#Based ;DIR< Approach% Te 5o#rnal o! *evelopmental and


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The DIR/Floortime approach is a idely accepted and respected developmentalapproach for individuals ith disorders of relatin! and communicatin!% It is $ased uponsolid research' and is the $asis for current active investi!ation as the field advances% It isin 2!eneral physician practice3 as indicated $y its reference in the most recent AmericanAcademy of ediatrics "Tool)it for Autism%&

Trailer bill lang#age: egional centers are proibited !rom p#rcasing e%perimentaltreatments$ terape#tic services or devices tat ave not been clinicall" determined or

scienti!icall" proven to be e!!ective or sa!e or !or wic risks and complications are

#nknown' E%perimental treatments o! terape#tic services incl#de e%perimental

medical or n#tritional terap" wen te #se o! te prod#ct !or tat p#rpose is not ageneral p"sician practice'

It ould $e an error to consider the leadin! developmental approach as "experimental&hen it is in fact a hi!hly effective approach hich $enefits many children and families%

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EvidenceBasefortheDIRModel_Cullinane090109