Leala Gonzales, LSWAssessing Autism Interventions

June 10, 2010

Database SourcesAcademic Search PremierERICMasterFILEPsycINFOPubMedwww.asatonline.opgwww.playproject.orgwww.icdl.comwww.yorku.ca

The DIR/Floortime Model What is DIR/Floortime?

• History• Developmental, Individual-based, Relationship

Model• Six Developmental Milestones • FloortimeWhat does DIR/Floortime claim to do?• Who does it address?• What does it do?What evidence supports the model?• Research• New ResearchConclusions

History of DIRDeveloped by Dr. Stanley GreenspanDuring residency became interested in working with

young childrenBegan his search for a new framework for

understanding human development As Director of Mental Health Study Center at NIMH

created a dept. in clinical infant development Synthesized what predecessors theorized looking

specifically at affect, cognition, motor and sensory development

Followed children from “bottom-up” to develop an affect-based approach

http://www.icdl.com/portal/node/53

DIR: The Developmental, Individual-based, Relationship Model

DevelopmentalThe building blocks of the ModelUnderstanding stage of development is critical to planning treatment

Six Developmental Milestones describe the steps of development that every child needs to master for healthy growth

Individual differencesThe unique biologically-based way each child takes in, responds to and

eventually understands the world around him/her

Biological challenges that interfere with growing and learning

http://www.icdl.com/dirFloortime/overview/index.shtml

Relationship-based The learning relationship with caregivers, teachers,

therapists, siblings, peers, etc. who interact with the child to master the stages of development

http://www.icdl.com/dirFloortime/overview/index.shtml

Six Developmental Milestones

1. Self-regulation2. Forming relationships3. Two-way purposeful communication4. Complex communication5. Creating emotional ideas6. Emotional thinking

(Greenspan & Weidner, 1998)

FloortimeDescription – Greenspan’s method of creating an environment based on play that

engages a child by following their lead during activities of interest Observes the child to clue adult into how to approach child Strives to develop pleasure in relating to others rather than teaching

a specific skill Play is at the child’s level (focusing on strengths not deficits) Extending or expanding the play by creatively intruding (to open

circles of communication) physically or verbally Encouraging the child’s interest in communication (verbal and

nonverbal) Stimulating the movement through the Six Developmental Milestones Method used by parents (under direction of Floortime specialists)

and other professionals Can be done at home, in treatment centers, in school

(Heflin & Simpson, 1998)

(Metz, Mulick, & Butter, 2005)

Floortime ComponentsHome-based – Heart of the program is this component

to allow practice of skills in the naturalistic comfort and security of the home

Up to eight 20-30 minute sessions daily are optimal25 hours/week

Therapeutic Team – Speech therapy, Occupational therapy trained in SI, Physical therapy

Three or more 45 min. sessions/week depending on individual differences

Educational Program – Integrated small class(up to 3 special needs children)

Special education teacher, early childhood teachersTherapists coming into class

http://www.icdl.com/dirFloortime/overview/GuidelinesforComprehensiveApproach.shtml

What does DIR/Floortime claim to do?Who does DIR/Floortime address?

ASD Down Syndrome Severe ADHD Cerebral Palsy Fetal alcohol SyndromeCommunication delay regulatory problems

What does Floortime do?Finds the parts of central nervous system that create developmental challenges

and working to improve them:Sensory system- taking information in from the world through our sensesProcessing system-making sense or interpreting of the information received through the sensory systemMotor system- physically responding to that information

(Greenspan & Weidner, 1998)

Move child along the developmental ladderAssessment of growth is measured using the FEAS (Functional Emotional

Assessment Scale) by looking at the child’s ability to:Organize play interactions with persons and objectsSelf-regulate mood and attentionForm attachments to caregiverEngage in reciprocal emotional interactions and communicationsRepresent feelings and ideas and engage in emotional thinking through play

interaction

http://www.icdl.com/dirFloortime/research/FunctionalEmotionalAssessmentScale.shtml

What evidence supports the model?Pilot Study of a Parent Training Program for Young Children with Autism.

The PLAY Project Home Consultation Program Sixty-eight children completed 8–12 month program Parents delivered 15 hours per week of 1:1 interaction Pre/post ratings of videotapes by blind raters using the Functional Emotional

Assessment Scale (FEAS) showed significant increases (p ≤ 0.0001) in child subscale scores. Translated clinically, 45.5 percent of children made good to very good functional developmental progress.

No significant differences between parents in the FEAS subscale scores at either pre or post intervention

All parents scored at levels suggesting they would be effective in working with their children.

Overall satisfaction with PPHC was 90 percent Despite important limitations, this pilot study of The PLAY Project Home Consulting

model suggests that the model has potential to be a cost-effective - Average cost of intervention was $2500/year.

Weaknesses: More measures of development are needed (IQ, language) Inaccurate estimates of interaction time by parents Did not study if outcomes would generalize to other

environments(Solomon, Necheles, Ferch, & Bruckman, 2007)

Evaluation of the efficacy of a seven week public school curriculum based on DIR/Floortime parent training program for parents of children on the autism spectrum Investigated the effectiveness of a 7 week DIR/Floortime

parent training on:Quality of parent-child dyadChild’s developmental level

Assessed using: Functional Emotional Assessment Scale (FEAS)Neuro-Developmental Disorders of Relating and

Communication Functional Emotional Development Levels (NDRC-FEDL)

Results: significant in both quality of dyad and increased developmental level

(Pilarz, 2009)

Developmental progress of children with pervasive developmental disorder and/or sensory processing disorder enrolled in a DIR/Floortime therapy group

Longitudinal study of 20 children diagnosed with PDD and/or SPD Conducted at a pediatric therapy clinic Participants were from a DIR/Floortime based developmental play group Pre and post tests (13.5 month intervention) using Sensory Profile Studied developmental progress after intervention regarding age, time spent in

intervention, differences between the two ICDL diagnostic categories: regulatory-sensory and neurodevelopmental disorder

Results: No statistical significance found when age and time spent in intervention were

examined When diagnostic categories were compared, the neuroevelopmental group

“moved toward a typical range of functioning” according to Muritidis. Cannot be used to generalize to the greater population due to the limited

number of participants

(Muratidis, 2009)

Brief Report: Comparative ABA and DIR Trials in Twin Brothers with Autism

The parents of identical twin brothers interested in both approaches -age 2.4 years-diagnosed with severe speech-language delays and autism

Agreed to a pilot study of short-term interventions at James Madison University in Harrisonburg, VA Each worked with a graduate level speech-language pathology clinician under supervision of one of the

authors (holds a national certification in speech language pathology and teaches interventions in autism at the graduate level)

Each attended 16 of 18 sessions, missing two due to illness The Communication and Symbolic Behavior Scales (Weatherby and Prizant, 1999) were used to test them

at the initial and final sessions Scored by clinicians and then by their supervisor to ensure accuracy The boys also were provided speech therapy services at their school twice a week, but neither ABA nor DIR

programs were used

(Hilton, & Seal, 2007)

Weekly conferences between clinicians and supervisor took place and included: A review of at least one videotaped session per week A review of the supervisor's observation notes Discussion of each boys interventions regarding implementation of

treatment, activities for the session and issues of behaviorPlans for each session with boys coordinated using similar toys, books

and snacksData was tallied by graduate students (who did not know the boys'

diagnoses nor the interventions) viewing videotapes regarding vocal, gestural and verbal responses to communication opportunities and negative behaviors

No other data taken to validate appropriate application of DIR and ABA- putting into question some treatment integrity

(Hilton, & Seal, 2007)

 

Limitations of study:Did not employ the intensive treatment time commitments

typical of both interventionsThe outcome was based solely on the results of the CSBSThe impact of possible differences in each clinician's skill

level in the intervention program Generalizing the results to other individuals is guarded

(Hilton, & Seal, 2007)

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

By Dr. Stanley I. Greenspan & Dr. Serena Wieder (2005)

Relationship Focused Early Intervention With Children With Pervasive Developmental Disorders and Other

Disabilities: A Comparative Study

Study by Mahoney and Perales (2005)compares the effects of relationship-focused early intervention on toddlers and preschool-age children who were classified as PDDs (N = 20) or developmental disabilities (N = 30)

Conducted over a 1-year period Weekly parent-child sessions focused on showing parents to use

responsive teaching strategies to encourage children to acquire and use pivotal developmental behaviors that addressed their individualized developmental needs

Results: Before/after comparisons indicated significant increases in parents’

responsiveness and children’s pivotal behavior Both groups of children made significant improvements in cognitive,

communication, and socio-emotional functioning Children with PDDs made statistically greater improvements on the

developmental measures than children with DDs. On several developmental measures, children’s improvements were

related to increases in both their parents’ responsiveness and their own pivotal behavior

http://www.icdl.com/dirFloortime/research/index.shtml

Educating Children with Autism” (National Academy of Sciences, Committee on Educational Interventions for Children with Autism, NRC, 2001) Cites ten programs with some evidence of being effective

three -based on developmental, relationships, and family support two -highly structured behavioral programs; and four -combined elements including a movement toward more

naturalistic teaching methods There is research support for a number of approaches, including DIR/Floortime and

behavioral interventions There are no proven “relationships between any particular intervention and children’s

progress” (p. 5) and “no adequate comparisons of different comprehensive treatments” (p. 8).

NAS (2001) analysis further notes that “studies have reported that naturalistic approaches are more effective than traditional discrete trial at leading to generalization of language gains to natural contexts.”

These behavioral approaches are becoming more similar to developmental, relationship-based models with the goal of creating learning relationships that build on a foundation for relating, communicating, and thinking.

http://www.icdl.com/dirFloortime/NASRreport.shtml

http://www.icdl.com/dirFloortime/NASRreport.shtml

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

by Stanley I. Greenspan, M.D., & Serena Wieder, Ph.D. (1997)

New Research September 2009 - the NIMH awarded the P.L.A.Y. Project a $1.8 million

grant for a controlled trial of play-based autism therapy.

Conducting the 3-year study: Richard Solomon, MD Research-design guidance: Michigan State University, and community-outreach

support from Easter Seals Clinical Trial: randomized, controlled, and blinded Participants: five Easter Seals autism service locations Compares the outcomes:

60 children who participate in The P.L.A.Y. Project to of60 children who receive standard, community interventions

Before /after (12-month intervention) assessments to measure: developmental level, speech and language, sensory-motor profile, and social skills

Largest study of its kindhttp://www.playproject.org/about_research.php

New Research con’tThe P.L.A.Y. Project

P.L.A.Y. was developed by Dr. Solomon Application of DIR/ Floortime framework“Through structured monthly home visits focused on modeling, coaching

and video feedback, consultants train parents to engage their child with autism in ways that promote emotional connection and communication. By training parents to participate in their child’s intervention, the program also promises to be cost-effective. The P.L.A.Y. Project costs under $4,000 per year, in comparison with other interventions that cost $40,000 to $60,000 per year.”

http://www.playproject.org/about_research.php

New Research con’t

York University in Toronto, Canada

2005 Received $5 million to establish a research initiative from Milton and Ethel Harris

Stuart Shanker, research professor of psychology and philosophy, will work with a research team

Stanley Greenspan, chief advisor

http://www.yorku.ca/yfile/archive/index.asp?Article=4712

The last word from ICDL“There is a wide range of research and clinical

experience not just from the field of autism but from the field of early intervention and child development at large, which, when taken as a whole, provides considerable empirical support (far more than for more circumscribed approaches) for a comprehensive developmental model.”

http://www.icdl.com/bookstore/catalog/documents/p1(1234).pdf

Videos

Conclusions“Although Floortime is an approach that holds promise for engaging children

with autism and promoting their ability to relate to others, more empirical research is needed.”

(Heflin & Simpson, 1998, p. 211)

“ Based on scientific research to date, there is not enough evidence to conclude that DIR is an effective treatment for children with autism."

(Freeman, 2007, p. 141)

“Level of research support was found to be Emerging (one or more studies indicate favorable results, more studies are needed to determine the intervention is effective).”

(National Standards Project, 2010, p. 20)

Conclusions con’t In Interventions for Autism Spectrum Disorders: State of the evidence (A

collaboration of the Maine Department of Health and Human Services & the Maine Department of Education) October 2009

Established six levels of evidence:

Level 1: EstablishedLevel 2: Promising EvidenceLevel 3: Preliminary EvidenceLevel 4: Studied and No Evidence of EffectLevel 5: Insufficiently StudiedLevel 6: Evidence of Harm

DIR/Floortime falls under Level 5: "Conclusions cannot be drawn on the efficacy of

the intervention due to a lack of quality research, or mixed results in several studies.”

http://www.asatonline.org/pdf/winter2010.pdf p. 3

Conclusions con’tMetz et al (2005) stated, “ The lack of empirical support is unfortunate

because, although this form of intervention remains unsupported, we find elements of the Floortime intervention of interest. At it’s core the model seems to incorporate an intensive form of incidental teaching, creating and capitalizing on interaction and instructional opportunities and teaching new skills using shaping and reinforcement. These concepts of intervention are important to teaching and generalization of skills that should be an integral part of any intensive intervention program. The emphasis on increasing parent sensitivity to, and in practice and generalization of skills in natural setting is one, in our experience, that is occasionally missing from many home intensive intervention programs based on principles of applied behavioral analysis." (p. 258)

Questions????

ReferencesFreeman, S. K. (2007). The Complete Guide to Autism Treatments. Lynden, Wa.: SKF Books.Greenspan, S. I., & Weidner, S. (1998). The Child with Special Needs. Reading , Ma.: Perseus Books.Heflin, L., & Simpson, R. (1998) Interventions for Children and Youth with Autism: Prudent Choices in a

World of Exaggerated Claims and Empty Promises. Part I: Interventions and Treatment Option Review. Focus on Autism & Other Developmental Disabilities, 13 (4) , 194-211. Retrieved from MasterFILE Premier database

Hilton, J. C., & Seal, B. C. (2007). Brief Report: Comparative ABA and DIR Trials in Twin Brothers with Autism. Journal of Autism & Developmental Disorders, 37 (6), 1197-1201. doi:10.1007/s10803-006-0258z

Metz, B., Mulick, J. A., & Butter, E. (2005)Autism: A Late 20th Century Fad Magnet in Jacobson, J. W., Foxx, R. M., & Mulick, J. A. Controversial Therapies for Developmental Disabilities: Fad Fashion, and Science in Professional Practice. (pp.237-264) New York: Ruetledge.

Muratidis, H. (2009). Developmental progress of children with pervasive developmental disorder and/or sensory processing disorder enrolled in a DIR/Floortime therapy group (Doctoral dissertation ,Adler School of Professional Psychology, 2009). Proquest Dissertations And Theses, Section 1143, Part 0622.

National Autism Center. (2009). National Standards Project Findings and Conclusions. Randolph, Ma.Pilarz, K. (2009) Evaluation of the efficacy of a seven week public school curriculum based on

DIR/Floortime parent training program for parents of children on the autism spectrum (Doctoral dissertation, Temple University , 2009) . Dissertation Abstracts International, 69, 122A.

Solomon, R., Necheles, J., Ferch, C., & Bruckman,D. (2007). Pilot study of a parent training program for young children with autism. Autism 11 (3), 205-224.

Referenceshttp://www.asatonline.org/pdf/winter2010.pdfhttp://en.wikipedia.org/wiki/Ego_psychologyhttp://www.icdl.com/bookstore/catalog/documents/p1(1234).pdfwww.icdl.com/dirFloortime/overview/index.shtmlhttp://www.icdl.com/portal/node/53http://www.icdl.com/dirFloortime/overview/DevelopmentalMilestones/Stage6.shtmhttp://www.icdl.com/dirFloortime/overview/GuidelinesforComprehensiveApproach.shtmlhttp://www.icdl.com/dirFloortime/research/FunctionalEmotionalAssessmentScale.shtmlhttp://www.icdl.com/dirFloortime/overview/index.shtmlhttp://www.icdl.com/portal/node/53 http://www.objectrelations.org/orkey.htmhttp://www.playproject.org/about_research.phphttp://www.yorku.ca/yfile/archive/index.asp?Article=4712