DIR Method and Autism Ranking: Limited positive evidence

Status Research

There are a number of limitations to all of the research studies published to date. For example

  • Two of the studies (Mok and Chung, 2014; Wieder and Greenspan, 2003) are purely descriptive in nature and contain insufficient data to evaluate the effectiveness of the DIR Method
  • Two of the studies described comprehensive, multi-component programmes based on the DIR Method but incorporating a wide range of individual techniques  (Casenhiser et al, 2013, MEHRIT programme;  Solomon et al, 2014, (PLAY) Project Home Consultation program ) making it difficult to  be clear which parts of the programme, if any, were responsible for any improvements.
  • Two of the studies (Casenhiser et al, 2015; Pajareya and Nopmaneejumruslers, 2012) are follow up studies of previous studies and cannot therefore be considered as separate trials, although they do contain useful data
  • One of the studies (Sealy and Glovinsky, epub) did not indicate how many of the participants were on the autism spectrum, making it impossible to evaluate the effect on the autistic participants
  • Some of the studies (Dionne and Martini, 2011; Wieder and Greenspan, 2003; Hilton and Seal, 2007)  had either one or two participants, which is too small a number to draw any meaningful conclusions
  • None of the randomised controlled studies (such as Casenhiser et al, 2013; Pajareya and Nopmaneejumruslers, 2011;  Sealy and Glovinsky, Epub; Solomon et al (2014)  were blinded, although all of them did include evaluations by blinded assessors
  • One study (Solomon et al, 2014) had very high levels of participant drop outs or data unavailable for analysis - 40 participants from a total of 128 participants
  • One of the studies (Wieder and Greenspan, 2003) was undertaken by researchers who were not independent of the intervention being studied. 

Systematic review by Mercer

The systematic review by Mercer (Epub) provides a useful analysis of some of the other limitations of these studies.

“These studies share a number of limitations. One important point is that they have not systematically compared DIR/Floor-time 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.”

For a comprehensive list of potential flaws in research studies, please see "Why some autism research studies are flawed."

31 Oct 2017
Last Review
01 Mar 2016
Next Review
01 Mar 2019