“D” Developmental
A developmental approach is founded on work by major developmental theorists such as Piaget, Vygotsky, Erikson, and Kohlberg. A developmental approach considers behavior and learning in the greater context of a developmental or changing process. DIR theory was first described by Dr. Greenspan in 1975 and was further developed over the next 20 years, especially through his collaboration with Serena Wieder, PhD. He received high honors and acclaim for his work including American Psychiatric Association’s highest award for child psychiatry research.
Greenspan, S.I, A Consideration of Some Learning Variables in the Context of Psychoanalytic Theory, (1975)
Greenspan, S.I. Intelligence and Adaptation, (1979)
Greenspan, S.I. Psychopathology and Adaptation in Infancy and Early Childhood (1981)
Greenspan, S.I. First Feelings (1985),
Greenspan, S.I. The Essential Partnership (1989)
Greenspan, S.I. The Development of the Ego (1989)
Greenspan, S.I. Infancy and Early Childhood (1992)
In 1997, Dr. Greenspan and Serena Wieder published, The Child with Special Needs: Encouraging Intellectual and Emotional Growth and in 2006 they published, Engaging Autism.
A description of the DIR model can also be found in this 1999 publication.
Greenspan, S. I., & Wieder, S. (1999). A functional developmental approach to autism spectrum disorders. Journal of the Association for Persons with Severe Handicaps, 24(3), 147-161. https://doi.org/10.2511/rpsd.24.3.147
In 1997, they reported the results of an extensive chart review of 200 children with autism who had received DIRFloortime. This showed the promise of the DIR/FT approach: The goal of the review was to reveal patterns in presenting symptoms, underlying processing difficulties, early development, and response to intervention in order to generate hypotheses for future studies. The chart review suggests that a number of children with autistic spectrum diagnoses are, with an appropriate intervention program, capable of empathy, affective reciprocity, creative thinking, and healthy peer relationships; that an intervention approach that focuses on individual differences, developmental level, and affective interaction may be especially promising;
Greenspan, S.I. and 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.
8 years later, they reported the follow-up of a subgroup of children, showing that it is possible for children with autism to become empathetic, creative, and reflective thinkers.
Greenspan, S.I. and Wieder, S. (2005) 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 (ASD) Who Received a Comprehensive Developmental, Individual-Difference, Relationship-Based (DIR) Approach. The Journal of Developmental and Learning Disorders 9.
Previous approaches using behavioral principles relied upon outside motivators on the premise that children with autism did not have their own motivation to participate in social interaction or to learn. The DIR/Floortime approach revealed that all children will show purpose and initiative and will seek close social relationships when provided with interactions which respect their interests and are tailored to their individual differences.
In 2009, 20 authors, representing 17 major institutions, and 3 countries collaborated to write a paper which outlines principles of assessment and effective intervention for children with suspected autism under the age of 2. They concluded “Interventions should ultimately be directed toward specific functional concerns and be informed by key developmental principles, including the child’s role as an active learner, the social contexts of learning, and the pivotal role of the parent-child relationship.”Zwaigenbaum et al (2009), Clinical Assessment and Management of Toddlers with Suspected autism spectrum disorder: Insights from studies of High-risk infants.
In 2010, Wallace and Rogers published a review of controlled studies which identified four factors which were most important for effective intervention for infants with autism. These were: “(1) parent involvement in intervention, including ongoing parent coaching that focused both on parental responsivity and sensitivity to child cues and on teaching families to provide the infant interventions, (2) individualization to each infant’s developmental profile, (3) focusing on a broad rather than a narrow range of learning targets, and (4) temporal characteristics involving beginning as early as the risk is detected and providing greater intensity and duration of the intervention.”
Wallace Katherine S. and Rogers Sally J. Intervening in infancy: implications for autism spectrum disorders Journal of Child Psychology and Psychiatry (2010)
Developmental intervention models are incorporating these elements, which are all fundamental features of the DIRFloortime approach.
The following are some of the research studies that report the effectiveness of developmental approach since 2000:
In 2002, a report of a developmentally based early intervention program for children with autism in Scotland showed significant improvement in children.
Salt 2002 The Scottish Centre for Autism preschool treatment programme The National Autistic Society Vol 6 (1) 33
See Salt 2001 for a description of the program:
Salt, J., Sellars, V., Shemilt, J., Boyd, S., Coulson, T., & McCool, S. (2001). The Scottish Centre for Autism preschool treatment programme: I: A developmental approach to early intervention. Autism, 5(4), 362-373.
In 2004, Aldred et. al. conducted a pilot randomized controlled trial of an intervention that focused on sensitive adult responses and promoting parent-child communication. The active treatment group showed significant improvement on ADOS total score, social interaction, language, parent-child interaction.
Aldred, C., Green, J., & Adams, C. (2004). A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45(8), 1420-1430.
See the following for a description of the intervention:
Aldred, C., Phillips, R., Pollard, C., & Adams, C. (2001). Multidisciplinary social communication intervention for children with autism and pervasive developmental disorder: the Child’s Talk project. Educational and child psychology, 18(2), 76-87.
In 2012, Aldred et al. published an analysis of the 2004 study showing the mediational effects of the intervention.
Aldred, C., Green, J., Emsley, R., & McConachie, H. (2012). Brief report: Mediation of treatment effect in a communication intervention for pre-school children with autism. Journal of Autism and Developmental Disorders, 42, 447-454 https://link.springer.com/article/10.1007/s10803-011-1248-3
In 2003 and 2005 Mahoney reported positive outcomes for an approach called Responsive Teaching. This approach focused on parent responsivity with results on improved child outcomes. In 2009, Mahoney further described “Relationship-Focused Intervention” as a “key element in early intervention.”
Mahoney, G., & Perales, F. (2003). Using relationship-focused intervention to enhance the social—emotional functioning of young children with autism spectrum disorders. Topics in Early Childhood Special Education, 23(2), 74-86.
Mahoney, G., & Perales, F. (2005). Relationship-focused early intervention with children with pervasive developmental disorders and other disabilities: A comparative study. Journal of Developmental & Behavioral Pediatrics, 26(2), 77-85.
Mahoney, G. (2009). Relationship Focused Intervention (RFI): Enhancing the Role of Parents in Children’s Developmental Intervention. International journal of early childhood special education, 1(1).
In 2018, Alquraini et al. published a RCT showing positive effects for children with autism using responsive teaching in social language and fine motor areas.
Alquraini, T., Al-Odaib, A., Al-Dhalaan, H., Merza, H., & Mahoney, G. (2018). Feasibility of responsive teaching with mothers and young children with autism in Saudi Arabia. Journal of Early Intervention, 40(4), 304-316.
In 2019, a secondary analysis of that study showed that parents showed improvement in stress and depression.
Alquraini, T, Al-Adaib, A., Al-Dhalaan, H., Merza, H., & Mahoney, G. (2019). Relationship based intervention with young children with autism in Saudi Arabia: Impediments and consequences of parenting stress and depression. International Journal of Disability Development and Education, 66, 233-248. https://doi.org/10.1080/1034912X.2018.1487042
In 2007, Schertz and Odom reported positive outcomes on a developmental intervention called Joint Attention Mediated Learning (JAML) with parent-mediated intervention for toddlers with autism.
Schertz, H. H., & Odom, S. L. (2007). Promoting joint attention in toddlers with autism: A parent-mediated developmental model. Journal of autism and developmental disorders, 37(8), 1562-1575.
In 2013, Schertz et al. reported an initial RCT of JAML and in 2018, Schertz et al. reported a subsequent RCT of JAML showing positive effects on social communication.
Schertz, H. H., Odom, S. L., Baggett, K. M., & Sideris, J. H. (2013). Effects of joint attention mediated learning for toddlers with autism spectrum disorders: An initial randomized controlled study. Early Childhood Research Quarterly, 28(2), 249-258.
Schertz, H. H., Odom, S. L., Baggett, K. M., & Sideris, J. H. (2018). Mediating parent learning to promote social communication for toddlers with autism: Effects from a randomized controlled trial. Journal of autism and developmental disorders, 48, 853-867.
In 2007, Solomon reported a pilot study on the Play Project which showed significant increases in child subscale scores on the FEAS after an 8-12 month program using Floortime.
Solomon, R., J. Necheles, C. Ferch, and D. Bruckman. “Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation program.” Autism 11, no. 3 (2007) 205-224.
In 2014, Solomon et al. reported their findings on a large randomized controlled trial conducted with 128 children with autism, that used a manualized, parent-mediated intervention program called the PLAY Project, which is based on the DIRFloortime approach. Parents showed marked improvement in the ability to read their child’s cues, follow their child’s lead, and obtain reciprocal social exchanges. Children showed marked improvement in engagement and initiation and functional development.
Solomon R, Van Egeren L, Mahoney G, Quon-Huber M, Zimmerman P. (2014) PLAY Project Home Consultation Intervention Program for Young Children with Autism Spectrum Disorders: A Randomized Controlled Trial. J Dev Beh Pediatrics. 35(8): 475-485.
In June 2011, Pajareya published a pilot RCT of DIRFloortime with preschool children with ASD. Results showed improvements in FEAS, CARS, and the functional emotional questionnaires, confirming the results of the Solomon 2007 study. She then conducted a second study over 12 months, also with positive outcomes.
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.
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.
In 2019 Pajareya et al. reported a RCT using DIR with children with developmental disabilities, showing improvements in attention and initiation.
Pajareya, K., Sutchritpongsa, S., & Kongkasuwan, R. (2019). DIR/Floortime® parent training intervention for children with developmental disabilities: a randomized controlled trial. Siriraj Medical Journal, 71(5), 331-338.
Elder et. al (2010) demonstrated significant changes in child and parent behaviors as a result of training fathers in following their child’s lead, imitating with animation, commenting on the child’s actions and expectant waiting. There were significant changes in the child’s behaviors, including increase in child initiating, and child’s non-speech vocalizations.
Elder, J.; O’Donaldson, S.; Kairella; J; Valcante, G; Bendixon, R; Ferdig, R; Self, E; Walker, J; Palau, C & Serrano, M. (published online 2010). In-home training for fathers of children with autism: A follow up study evaluation of four individual training. Journal of Child Family Study. 20(3); 263-271.
In 2010, building on the earlier study by Aldred, Green et.al. reported positive results from the PACT program (Preschool Autism Communication Trial), a parent-mediated training program, which was effective in increasing parental sensitivity and responsiveness, with increased child initiations and parent-child attention.
Green, J.; Charman, T.; McConachie, H.; Aldred, C.; Slonims, V.; Howlin, O.; Le Couteur, A.; Leadbitter, K.; Hudry, K.; Byford, S.; Barrett, B.; Temple, K.; MacDonald, W.; Pickles,A.; & the PACT Consortium (2010). Parent mediated communication-focused treatment in children with autism (PACT): A randomized controlled trial. Lancet. 2010 Jun 19; 375(9732): 2152–2160.
In 2016, Pickles et.al. did at follow-up of the PACT study after 5.75 years, which showed long-term benefit of the early intervention.
Pickles, A., Le Couteur, A., Leadbitter, K., Salomone, E., Cole-Fletcher, R., Tobin, H., … & Aldred, C. (2016). Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomized controlled trial. The Lancet, 388(10059), 2501-2509.
In 2023, Carruthers et al. found that child initiations mediated the majority of the treatment effect in the above long term benefit study.
Carruthers, S., Pickles, A., Charman, T., McConachie, H., Le Couteur, A., Slonims, V., Howlin, P., Collum, R., Salomone, E., Tobin, H., Gammer, I., Maxwell, J., Aldred, C., Parr, J., Leadbitter, K., & Green, J. (2023). Mediation of 6‐year mid‐childhood follow‐up outcomes after pre‐school social communication (PACT) therapy for autistic children: a randomized controlled trial. Journal of Child Psychology and Psychiatry. https://doi:10.1111/jcpp.13798
Also in 2016 Rahman utilized the same treatment in India and Pakistan with positive effects.
Rahman, A., Divan, G., Hamdani, S. U., Vajaratkar, V., Taylor, C., Leadbitter, K., … & Patel, V. (2016). Effectiveness of the parent-mediated intervention for children with autism spectrum disorder in south Asia in India and Pakistan (PASS): a randomised controlled trial. The Lancet Psychiatry, 3(2), 128-136.
A developmental treatment called SPEIC- Scheme to promote early interactive conversation- was studied over a 12 month period in 10 children with ASD or children at risk for ASD. The outcomes included increase in attention, joint attention and communication.
Smith, C., & Bohane, L. (2010). Isle of Wight study: a neuro-developmental therapy to promote social attention and shared emotion in young children with high-functioning autistic spectrum difficulties. Procedia-Social and Behavioral Sciences, 5, 698-706.
For further information about this approach see:
Smith, C., Goddard, S., & Fluck, M. (2004). A scheme to promote social attention and functional language in young children with communication difficulties and autistic spectrum disorder. Educational Psychology in Practice, 20(4), 319-333.
In 2011, a single subject study design was used to evaluate the effectiveness of Floor Time Play with a 3.6 year-old boy with autism. The study used an observation and intervention phase and utilized circles of communication as the measure of change. Results showed a significant improvement using Floor Time play strategies, and mother’s journal included insights on the changes observed.
Dionne and Martini, Revue canadienne d’ergotherapie; June 2011 78 (3)
In a randomized controlled trial, Casenhiser et al. (2011-online date) presented the results of a DIRFloortime based, social-communication intervention. A significant association was found between improvements in caregiver behaviors and improvements in children’s social-communicative measures. Results indicate that the treatment group showed significantly greater enjoyment in interactions with their parents, were significantly more attentive and involved in interactions with their parents and initiated more joint attention. Initiation of joint attention and involvement were predictive of increase in language skills.
Casenhiser, D. M., Shanker, S. G., & Stieben, J. (2013). Learning through interaction in children with autism: Preliminary data from asocial-communication-based intervention. Autism, 17(2), 220-241.
Casenhiser et. al. (2015) reanalyzed their data from their 2011 research and documented that the children in the treatment group outperformed the community treatment group on measures of language including, number of utterances produced, and various speech act categories such as sharing, commenting, rejecting/protesting, social conventions and responses to comments.
Casenhiser, D. M., Binns, A., McGill, F., Morderer, O., & Shanker, S. G. (2015). Measuring and supporting language function for children with autism: Evidence from a randomized control trial of a social-interaction-based therapy. Journal of Autism and Developmental Disorders, 45, 846-857.
In 2013, Siller et. al. conducted a randomized, clinical trial with 70 children with ASD, 6 years of age or younger, using Focused Playtime Intervention (FPI). The intervention was designed to promote responsive parental behaviors in a family-centered intervention. The intervention focused on play, social engagement, and encouraging increasingly complex child communication and play. Results showed a significant treatment effect on responsive parental behaviors and a conditional effect on children’s expressive language outcomes, showing that children with baseline language skills below 12 months are most likely to benefit from FPI.
Siller, M; Hutman, T & Sigman, M. (2013). A parent-mediated intervention to increase responsive parental behaviors and child communication in children with ASD: A randomized, clinical trial. Journal of Autism and Developmental Disorders. March. 43(3), 540-550.
In 2014, Siller et.al. reported that Focused Playtime Intervention (FPI), also increases attachment related behaviors.
A Parent-Mediated Intervention that Targets Responsive Parental Behaviors Increases Attachment Behaviors in Children with ASD: Results from a Randomized Clinical Trial. Siller, Michael; Swanson, Meghan; Gerber, Alan; Hutman, Ted; Sigman, Marian. Journal of Autism and Developmental Disorders, v44 n7 p1720-1732 Jul 2014
In 2014, Liao and colleagues conducted a study on the effects of the DIR/Floortime intervention with eleven children with autism (ages 45-69 months). The mothers were trained in DIRFloortime during pre-intervention 1:1 counseling sessions and a three-hour lecture. Each parent conducted the intervention for at least 10 hours a week for ten weeks. There were significant improvements in each child’s two-way communication, behavioral organization and problem-solving and daily living skills with medium to large effect sizes.
Liao, S.; Hwang, Y; Chen, Y.; Lee, P.; Chen, S & YiLin. (2014). Home-based DIR/Floortime intervention program for preschoolers with autism spectrum disorders: Preliminary findings. Physical and Occupational Therapy in Pediatrics. Early online: 1-12.
A 40-year program, called the Turtle Project, conducted a 4-year study of a comprehensive developmental relationship-based intervention for children with autism. Positive outcomes were found for autistic symptoms and cognitive development.
Di Renzo, M., Di Castelbianco, F. B., Petrillo, M., Racinaro, L., & Rea, M. (2015). Assessment of a long-term developmental relationship-based approach in children with autism spectrum disorder. Psychological reports, 117(1), 26-49.
Di Renzo, M., Bianchi di Castelbianco, F., Vanadia, E., Petrillo, M., Racinaro, L., & Rea, M. (2016). From the emotional integration to the cognitive construction: the developmental approach of turtle project in children with autism spectrum disorder. Autism Open Access, 6(1), 160-9.
In 2017, Sindelar published a brief report showing the effectiveness of DIR for a group of autistic children with severe challenges.
Sindelar MT, Furland N. Outcomes in a Group of 7–8-Year-Old Children in a Developmental-Based Intervention in Autism Spectrum Disorder. European Psychiatry. 2017;41(S1):s304-s304. doi:10.1016/j.eurpsy.2017.02.192
In 2018, Reis et.al. reported the outcome of an intervention based on DIRFloortime for 25 children, 3-6 years of age, over 10 months. Positive effects were found on social communication and sensory processing.
Reis, H. I., Pereira, A. P., & Almeida, L. S. (2018). Intervention effects on communication skills and sensory regulation on children with ASD. Journal of Occupational Therapy, Schools, & Early Intervention, 11(3), 346-359.
In 2019, Ho and Lin reported a RCT of a DIR program in Taiwan, conducted over 14 weeks. They report benefits in emotional development and parenting skills.
Ho, M. H., & Lin, L. Y. (2020). Efficacy of parent-training programs for preschool children with autism spectrum disorder: A randomized controlled trial. Research in Autism Spectrum Disorders, 71, 101495.
As this list demonstrates, research continues to advance showing the effectiveness of developmental approaches broadly, and DIRFloortime specifically.