Examining DIR/Floortime™ as a Treatment for Children With Autism Spectrum Disorders

Stages and Goals of DIR

Greenspan (1992) discussed six stages in early childhood development. The typical outcomes of these stages provided therapeutic goals for working with autistic children.

The stage of homeostasis, typically occurring between birth and 3 months of age, ideally culminates in internal regulation and a balanced interest in the world but may conclude with unregulated or withdrawn behavior (regulatory disorders) if caregivers are unavailable, chaotic, dangerous, abusive, or dull.

Techniques of DIR/Floortime™

DIR/Floortime™ works toward the achievement of each of the early adaptive goals in children who show, by autistic or other symptoms, that they have not completely achieved adaptive solutions to the tasks of one or more particular phases. According to Lal and Chhahbria (2013), “Floor time intervention aims at taking the child back to the first milestones that the child may have missed in the process of development” (p. 698). In order to accomplish this, DIR/Floortime™ uses one-to-one interactions between a therapist and a trained parent and carries these out literally on the floor in a child’s natural play environment. DIR/Floortime™ begins with the adult’s observation of the child and assessment of his or her activities, interests, and emotional state. He or she then approaches the child and joins in whatever she may be doing, imitating the child’s actions but labeling them with words and gestures and expressing interest and positive affect, thus bidding for communication with the child. Whatever the child does, the adult follows the child’s lead and supports organization and elaboration of ideas and feelings. The adult expands on the child’s play by commenting on connections with familiar events. The goal is to achieve “closed circles of communication” or interactions in which the adult approaches and the child responds, whether by speech, gaze, gesture, or movement. Turn-taking would be an important example of closing a circle of communication.

How the intervention is actually carried out depends to some extent on what the environment offers. Activities like block-building, bead-stringing, and pretend play with dolls, toy cars, or toy animals all lend themselves to therapeutic use. Whatever is used, it must be interesting to the child and thus be helpful for producing engagement with the adult. Greenspan’s (2001) “affect diathesis hypothesis” states that when interactions with adults are pleasurable and contingent on the child’s cues, the child’s inherent tendency is to progress through the series of increasingly high levels of social competence and to lose previous symptoms of autism. Much of the posited effect of DIR/Floortime™ would appear to result from the adult’s ability to assess a child’s interests correctly and to make their play experience engaging and pleasurable (Wieder & Greenspan, 2003).

The idea of therapy through play and engagement of the child raises obvious questions about what is to be done if the child does not play or engage. How does one follow the child’s lead if no lead is given? DIR/Floortime™ practitioners use a range of actions to move the process along. They do not treat the child’s refusal of a bid as rejection of the situation or themselves. They place themselves in front of the child. They may make a “wrong move” so the child will correct what has been done, do something playfully oppositional in the face of what the child tries to do (in much the way that caregivers play with typically developing infants by offering a toy and then pulling it away once or twice while smiling), or “play dumb” so the child must explain or indicate what is wanted. They do what the child tells them or “take turns” being in charge. They provide visual cues to an activity and have “sensorimotor breaks” in which swinging or other physical actions are encouraged.

A therapist doing DIR/Floortime™ in a child’s home can be seen at www.youtube.com/watch?v=h3gcpNcq29M. A video of Greenspan directing a family’s interactions with a child is at www.youtube.com/watch?v=vApghedypFc.

DIR/Floortime™ is not an intervention that can be done in an hour or two per week. In one outcome study to be discussed later in this article (Solomon, van Egeren, Mahoney, Huber, & Zimmerman, 2014), children received about 600 hours per year of DIR/Floortime™—about 15 hours a week—plus a couple of hours a week of speech therapy or other interventions. Greenspan (1992) recommended daily Floortime sessions with parents, two weekly sessions each with speech and occupational therapists, parent counseling once or twice a week, and four individual psychotherapy sessions per week. Greenspan commented that if “the mother is at home, she can do floor time three or four times a day. Such a pattern has helped children with autistic features become more pleasurably engaged in two-way communication within six months” (1992, p. 699). (As has been pointed out elsewhere, the demands of DIR/Floortime™ may result in a self-selection bias among parents choosing the intervention; they are also reminiscent of the requirements of Lovaas’s, 1987, original ABA study that parents take a year off from work to participate in the intervention.) It should be noted, however, that the outcome studies to be discussed later in this article apparently did not use in any systematic way the adjuvant treatments recommended by Greenspan.

Developmental Factors

To examine the sources of developmental considerations in DIR/Floortime™, we can begin by referencing Greenspan’s (1979) monograph integrating psychoanalytic and Piagetian theory. This work, entitled Intelligence and adaptation, introduces several important themes in Greenspan’s thinking. The first point is that both psychoanalytic assumptions about personality development and Piagetian theory are stage theories, a characteristic shared by DIR/Floortime™. Such theories presuppose that success or failure at one stage of development will contribute for good or ill to a later stage and that reworking of early problems (as seen in DIR/Floortime™) may be necessary for the solution of later-emerging difficulties. A second point revealed by the 1979 monograph is Greenspan’s essential connection of emotional and personality factors with intelligence, shown in DIR/Floortime™ in the proviso that the child’s pleasurable engagement with a situation is needed in order for learning to occur. Third, an essential point of the monograph title is “adaptation”; development is seen as shaping intelligence and behavior to suit an early environment, but the shape taken may prove to be either adaptive or maladaptive, as the child’s environment broadens and presents different demands.

Greenspan’s view of cognitive development differs from Piaget’s and those of other cognitive theorists. Piaget’s approach posited that cognition develops as a result of the inherent processes of assimilation and accommodation, which operate on sensory experiences to yield advances in cognitive abilities. Rewards or experiences of pleasure are not needed to stimulate or maintain developmental progress. Similarly, the idea of mastery motivation in young children stresses the reward value of mastering any task and the consequent self-motivation for cognitive and motor development (Yarrow et al., 1983). Greenspan’s view, on the other hand, derives intellectual development from pleasurable social interaction experiences. In his opinion, “affective interactions emerge earlier than the sensorimotor schemes postulated by Piaget … they are the most primary probes we use to understand, conceptualize, and ‘double code’ our experiences with the world … [and] most types of abstract thinking are based on reflections on these personal affective experiences” (Greenspan, 2001, p. 2). For Greenspan, an infant’s joy and pleasure in a caregiving relationship were necessary before learning could emerge from interactions within that relationship. This position shares some of the tenets of ego psychologists like Heinz Hartmann.

Individual Differences

The individual-differences aspect of DIR/Floortime™ has different sources than the other aspects. Greenspan’s interest in the contributions of occupational therapy led him to an emphasis on individual differences in sensorimotor patterns, as posited by the occupational therapist and theorist A. Jean Ayres, whose work is referenced by Greenspan (1992). Ayres (1979) formulated sensory integration theory (SIT), an approach that placed problems of mood, behavior, and intelligence in terms of young children’s abilities for sensory reactivity and processing. SIT, often used by occupational therapists, uses adjustments of sensory stimulation with the intention of altering a child’s state of arousal and fostering more mature processing abilities. Motor tone and motor planning abilities may be included in this process. Greenspan referred to these child characteristics as constitutional–maturational variables and listed them as follows: “1. Sensory reactivity, including hypo- and hyperreactivity in each sensory modality (tactile, auditory, visual, vestibular, olfactory); 2. Sensory processing in each sensory modality (e.g., the ability to decode sequences, configurations, or abstract patterns); 3. Sensory affective reactivity and processing in each modality (e.g., the ability to process and react to degrees of affective intensity in a stable manner); 4. Motor tone; 5. Motor planning” (1992, p. 14). DeGangi and Greenspan (1989a, 1989b) developed an instrument to assess these characteristics, but the instrument is not mentioned as having been used to guide treatment in the outcome studies to be discussed later in this article.

Although a considerable literature on infant temperament existed at the time when Greenspan was formulating DIR/Floortime™, and might be expected to have been a part of any individual-difference approach, Greenspan rejected considerations of temperament as inferior to assessment of constitutional–maturational individual differences. He noted that “temperament research relies on parental reports of the infant’s capacities, rather than ‘hands-on’ assessment of the infant. In addition, most temperament constructs tend to assume that there is a general tendency within the infant toward such global behaviors as introversion or extraversion, or shyness and inhibition. In [the DIR] model, these global behavioral tendencies are hypothesized to be secondary to highly specific ‘hands-on’ verifiable infant tendencies, such as tactile or auditory sensitivity or motor tone and motor planning difficulties” (1992, p. 23).

Greenspan’s interest in individual differences included the work on regulatory disorders of Porges (Portales, Porges, & Greenspan, 1990). Porges’ work on respiratory sinus arrhythmia as a factor in good development of young infants suggested an individual characteristic that could be relevant to development of regulatory and other disorders.

Recognizing the level of controversy about food and environmental allergies and sensitivities, Greenspan nevertheless recommended that if such factors were suspected of worsening child symptoms, it could be useful to avoid exposure for a period of 10 days to 2 weeks, then to challenge the child by reexposure. He recommended this approach for sleeping problems and irritability, and noted that “children with difficulties with modulating attention, activity, thinking, mood, or behavior, may benefit from exploration of dietary and environmental factors” (1992, p. 379). As was noted earlier about assessment of constitutional–maturational factors, this approach is not mentioned as part of recent outcome studies.

The “Relationship-Based” Component

Greenspan’s emphasis on DIR/Floortime™ as a relationship-based treatment is seen in his dual focus on child needs and the appropriate or inappropriate contributions of primary caregivers. The 1992 book discusses the motivation and actions of caregivers and notes the importance of their joy in the child and their efforts to draw the child into pleasurable social interactions. This view reflects the work of Bowlby (1982) and others on the development of emotional attachment of the child to the parent, but goes beyond Bowlby in consideration of details of events leading up to attachment. Greenspan referenced Margaret Mahler’s and René Spitz’s descriptions of relationship events in early infancy. With respect to motivation, his emphasis was, like Bowlby’s, on the pleasurable social nature of interactions that create attachment, rather than on a behavioristic view of physical needs and gratifications as sources of the attachment relationship.

Greenspan’s view of the importance of relationships gave emphasis to the role of parents as therapists. The power of the parent–child relationship gave trained and professionally supported parents a therapeutic capacity that allowed them to add essential experiences to the various professional treatments included in DIR/Floortime™.

Other Sources

The play aspect of DIR/Floortime™ resembles other play approaches in its stress on communication and relationships. Play approaches to therapy involve communication through toys, pretending, manipulation of objects, and other nonverbal techniques, as DIR/Floortime™ does. Some play methods, like Theraplay (Jernberg, 1979), have trained parents to work with children, again with the assumption that the strength of the relationship helps to make the play meaningful and therapeutic.

DIR/Floortime™ Treatment

The developmental aspects of DIR/Floortime™, discussed earlier in this article, are plausible in terms of their close agreement with steps in early development. Of these steps, attachment is the one that has received by far the greatest attention, with thousands of articles published on this topic since Bowlby’s day. Development prior to attachment has presented more challenges to research, and evidence about capacities in early infancy is still very much under investigation and often depends on high-technology methods of assessing the rapid behavior changes that can be interpreted as indicating infant moods or cognitions. As for the later developmental stages considered by Greenspan and his colleagues, some aspects of continued attachment development were described by Bowlby, and later work has been directed at negotiation and compromise abilities (e.g., Crockenberg, 1992). Nothing in DIR/Floortime™ is at odds with these established ideas and facts about development.

Consideration of individual differences and their effects on development has been an important part of the study of early development. Work on ASD presently includes investigation of genetic differences as sources of ASD and of differences in the severity of ASD (Beaudet, 2012). Such work has suggested that autistic children may become symptomatic because they have atypical needs for environmental support, whether dietary or otherwise. The genetics work is congruent with Greenspan’s emphasis on individual differences as determinants of appropriate therapeutic approaches. Concepts of temperament (Kagan, 1984), although their measures were rejected by Greenspan as inadequate for DIR purposes, are nevertheless congruent with DIR/Floortime™ thinking.

However, whether sensory capacities have the impact on development claimed by Greenspan is less certain. Ongoing work on auditory capacities, for example, shows that in typically developing infants the ability to attend selectively to sounds is more complex than DIR/Floortime™ authors have assumed (Kidd, Piantadosi, & Aslin, 2012). Given the continuing investigation of sensory development, it is questionable whether the methods of assessing sensory individual differences suggested by DeGangi and Greenspan (1989a, 1989b) can be known to be effective.

The relationship-based component of DIR/Floortime™ is also highly plausible in terms of established thinking about early development. From Vygotsky’s (1978) early statements about the supportive role of familiar adults in learning, to the whole body of work on the benefits to development of attachment, there is strong support for the importance of relationships in the support of development.

In general, then, the foundations of DIR/Floortime™ are plausible, both logical and congruent with established thinking about early development.

Adjuvant Methods

Adjuvant methods recommended by Greenspan (1992) are rarely mentioned in much detail in current accounts of DIR/Floortime™ outcome studies. Nevertheless, it is reasonable to examine their plausibility and evidence basis when considering DIR/Floortime™. Questions about recommended adjuvant methods are especially important for outcome research because of their implications for assurance of treatment fidelity. A later section of this article will discuss the adjuvant methods that may be used along with DIR/Floortime™, but the reader should keep in mind that the outcome research studies to be discussed in the next section do not necessarily use the same adjuvant methods for each treated child.

Randomized Controlled Studies

A small randomized controlled study by Pajaraya and Nopmaneejumruslers (2011) compared outcomes for a group of 28 preschool children, all of whose families were initially using ABA and a mixture of other services, speech therapy, and occupational therapy, and half of whom were randomized by an undescribed method to receive DIR/Floortime™ as well as their original community services. The intervention was directed entirely at the parents, who did about 15 hours of Floortime a week with their children. Significant improvement was seen in the treatment families, and there were better results when parents did more hours of Floortime, but this difference was not statistically significant. An unusual problem with this study was that all materials had to be translated into Thai, and the authors queried whether cultural differences might have had an effect.

Lal and Chhahbria (2013) reported random assignment to treatment and control groups of 26 children randomly selected from five preschools in Mumbai, but did not elaborate on how either random selection or random assignment to groups was done. The control group was said to receive the usual early intervention sessions provided in their educational settings. The treatment group received twenty 30-minute sessions of Floortime from therapists and parents. It was not clear whether the children continued to attend preschool, who administered the assessment and whether that person was blinded to the children’s group assignments, or how intervention fidelity was assured. Using a series of t-tests, Lal and Chhabria reported significant improvement of the treatment group over the control group for turn-taking, two-way communication, and cause and effect understanding, but not for emotional thinking.

Casenhiser et al. (2013) investigated the outcomes of a DIR-based intervention, the Canadian Milton and Ethel Harris Research Initiative treatment program. This article reported preliminary data about 51 children from an ongoing larger study. The children had been randomly assigned after stratification by age and language function to 12 months of DIR-like intervention or to 12 months of community treatment (some combination of speech therapy, ABA, occupational therapy, social skills group, specialized part-time day care, hyperbaric oxygen therapy, and/or specialized diets). In addition to Floortime, the DIR-like program stressed coregulation and sensorimotor supports, using swings and other occupational therapy equipment, lowering or raising sound levels, and brightening or dimming lights, to ensure a child’s optimal level of arousal. Four blinded coders assessed videotapes of interactions. The general quality of social interactions was reported as improving significantly in the treatment group, but language did not improve differentially.

Solomon, van Egeren, Mahoney, Huber, and Zimmerman (2014) reported on a randomized controlled trial of an intervention based on DIR, the Play and Language for Autistic Youngsters (PLAY) project. Computer-generated randomization with blocks of older and younger children, autism versus autistic spectrum diagnosis, and gender was used to assign 128 families either to a PLAY treatment group or to community services (free public preschool special education services and about 2 hours a week of private speech therapy). PLAY provided coaching, modeling, and video feedback to support 15 hours per week of parent work with children in addition to community services for the treatment group. The PLAY group received about 600 hours of parent treatment during the year, in addition to about 100 hours of community services, equivalent to the community services the other group received. The PLAY group was reported to show significant improvement relative to the control group on interaction skills, functional development, and autistic symptoms, but not on language.

Limitations of the Studies

These studies share a number of limitations. One important point is that they have not systematically compared DIR/Floortime™ to a treatment for which there is clear evidentiary support of effectiveness. The only such treatments are discrete trial methods, and although many of the children in both intervention and control groups were having some ABA treatment, the published reports do not include any information that enables readers to compare ABA to DIR as might be considered appropriate, given the empirical support for ABA. A second problem is that the studies are designed to compare DIR plus usual services to usual services alone; in other words, each DIR or DIR-like group receives many more hours of treatment than the control group does, raising the obvious question whether any positive effects are simply due to more interaction with adults rather than with DIR specifics. (This problem is present even in the sophisticated and carefully implemented Solomon et al., 2014, study.)

Additional limitations of these studies are very difficult to avoid and emerge from the difficulty of studying families as they function in their homes. Families dropped out of studies or changed their practices with their children as a result of learning what other parents were doing. How many hours were actually spent in Floortime could be known only from parent reports. Other services received by either the intervention or the control groups were not necessarily known, and if reported at the beginning of a study could well have changed by the end. Casenhiser et al. (2013) also noted that in their study there were unavoidable self-selection biases, as the parents involved had to be amenable to DIR methods, had to be able to attend training 2 hours a week, had to be able to complete assignments, and had to be able to spend at least 3 hours each day in interactions with one child.

Given the difficulties of this type of research, it seems reasonable to conclude that the existing studies give weak support to the effect of Floortime on some skills of autistic children, although improved language functioning is not among these. However, no independent replications of any of the studies have been carried out.

Adverse Events

No adverse events associated with DIR/Floortime™ have been reported for children or families. Because of Greenspan’s affect diathesis hypothesis, stating that experiences must be pleasant in order for developmental progress to be caused, there seems little chance of any direct harm to children, even the “emotional burden” considered a problem by Linden (2013). It is possible that the demanding schedule of DIR/Floortime™ could be harmful to parents and other children or to family interests that might be ignored because of the intervention’s requirements. And, of course, indirect harm can result from commitment to an ineffective treatment and rejection of more effective methods.

Speech Therapy

Speech therapy for autistic children was strongly recommended by Greenspan. This is a plausible recommendation in light of the speech and language deficits that are often the first indication of an autistic pattern of development. With respect to the effectiveness of speech therapy, a systematic review (Morgan et al., 2014) concluded that speech therapies had “primarily positive treatment effects on social communication skills” of autistic children (p. 252), but the review authors cautioned that many of the studies had weak designs.

SIT

A second important adjuvant method used when autistic children receive DIR/Floortime™ treatment is SIT. This treatment, generally done by occupational therapists, was recommended by Greenspan as part of therapy for ASD, although it has not been systematically included in outcome research on DIR/Floortime™.

Sensory integration, as originally defined by Ayres (1964), is a neurological process that organizes sensations from different modalities and parts of the body and allows the individual to use the body within the environment, including in this category social interactions with other people. Ayres posited sensory integration and processing disorders, which emerged from a cortical problem with balancing excitation and inhibition and achieving a balanced approach to central and peripheral nervous system activity. According to Ayres, such imbalances were associated with cerebral palsy, attention disorders, learning disabilities, and ASD. To treat such problems, Ayres (1979) proposed the use of full body movements that resulted in vestibular, tactile, and proprioceptive stimulation. She held that this kind of treatment would improve the functioning of the related sense organs. Sensory abilities, and the brain’s ability to organize related sensory information, were thought to improve as a result of swinging, balancing, and limb movement. “Sensory diets” also form a part of SIT. As described by Smith, Mruzek, and Mozingo (2005), they may include dimming or brightening of illumination, changes in sound levels, deep pressure techniques, brushing of the skin, weighted vests, textured toys, and the wearing of “body socks” to provide all-over pressure.

SIT techniques are plausible within the context of Ayres’ assumptions about disorders and her association of ASD with attention disorders and cerebral palsy. If ASD is a special case of difficulty with arousal and attentional control, using environmental changes to adjust arousal would be a logical ploy; if ASD is a different kind of disorder, as genetic studies seem to indicate, it is a mistake to focus on arousal as a focus of treatment, and it becomes difficult to see SIT as a plausible approach. Ayres’ claim that full-body movements of preschool children would improve the functioning of some of their sense organs is implausible in terms of what is known about sensory development. Myelination of pathways in the vestibular system is completed very early and unlikely to be affected by later stimulation (Gottlieb, 1971). Even development of neural pathways that are slower to myelinate is complete by preschool age. In addition to myelination issues, the claims of SIT appear unlikely in light of the fact that exposure to sensory stimulation generally leads to adaptation to the stimulus and a lessening of sensitivity. The plausibility of SIT as an adjuvant treatment for DIR/Floortime™ is thus questionable, although in a related area, infants who were later diagnosed as autistic did show a lack of age-typical anticipatory movement (Brisson, Warreyn, Serres, Foussier, & Adrien-Louis, 2012). Studies of SIT are difficult to carry out because of the treatment’s individualization and because of issues about measurement of sensory responses (see Mercer, 2014, pp. 158–159). However, publications over the last 30 years have repeatedly rejected the idea that SIT is supported by empirical evidence. Hoehn and Baumeister (1994) concluded that SIT was demonstrably ineffective. A 2009 review by Hyatt, Stephenson, and Carter agreed that there was no evidence supporting the effectiveness of SIT. Addison et al. (2012) discussed some of the difficulties of assessing SIT methods for treatment of feeding disorders and pointed out the need for further investigation.

Developmental Optometry

A current adjuvant treatment used with DIR/Floortime™ by some practitioners is developmental optometry, a method that claims to alter use of visual information through guided practice and, in conjunction with DIR, to help patients engage with therapy (Green, Wachs, & Dee, 2014). Although it is unclear whether Greenspan himself was in favor of the use of developmental optometry as an adjuvant treatment with DIR/Floortime™, his colleague Serena Wieder has written a coauthored book, published by the Profectum Foundation, asserting the usefulness of developmental optometry in the treatment of autistic children (Wieder & Wachs, 2012). This publication is advertised on the Profectum website. Methods used in developmental optometry include work on visual tracking, on block rotations, and on visual sequencing, all in the form of games. DIR/Floortime™ methods are used by some practitioners (Green et al., 2014) as ways to involve children in developmental optometry techniques, with goals of both improved visual/spatial capacities and emotional thinking.

The claims of developmental optometrists about ASD are not plausible in terms of congruence with established information. If good vision and visual processing were necessary for emotional or cognitive development, we would find that children blind or visually impaired from birth were unable to develop along typical lines of emotional or cognitive achievement, and this is not the case. However, it is possible that children genetically inclined to ASD may need different experiences than genetically typical children in order to attain more typical development and avoid autistic symptoms (Beaudet, 2012), and if this were the case, developmental optometry for autistic children might be a more plausible approach. In addition to these points, the claims that visual exercises can correct major visual problems are implausible in the context of known events of myelination and of cortical development of binocular cells; these events, essential to the shaping of visual functions, occur during a critical period, and under no presently known circumstances can they be refashioned when that period is over. The current stress on lasting neurological plasticity, a factor in beliefs about developmental optometry, largely ignores the fact that some functions of the nervous system follow critical period rules, while others do not; without the as yet undeveloped use of hormonal or other chemical treatments to restore a system to the plasticity of its critical period, changes such as those posited by developmental optometry are quite unlikely.

Problems of individualization and measurement cause difficulties for outcome research on developmental optometry. Nevertheless, a review sponsored by the British College of Optometrists (Barrett, 2009) considered research publications on this topic and concluded that although specific visual problems like amblyopia or convergence disorders could be helped by use of orthoptic methods, including prism lenses, most of the claims about successful treatment of dyslexia and other childhood disorders were without adequate foundation.