logo

DIR Method and Autism Ranking: Limited positive evidence

Mother and child with autism doing Floortime

The DIR Method (also known as Floortime, DIRFloortime or the Developmental, Individual Difference, Relationship-Based Model) is a comprehensive, multi-component intervention used to help children with educational, social-emotional, mental health, and/or developmental challenges.

The DIR Method is based on the idea that some children have difficulty reaching certain developmental milestones (such as two-way communication) and can be helped to meet those milestones through playful, structured interaction with an adult.

The key technique used within the DIR Method is a series of 'Floortime' exercises in which the carer takes an active role in spontaneous and fun activities that are directed by the child's interests and actions.

The DIR Method is usually delivered by parents, helped by a DIR Method consultant, who develops and oversees a programme personalised to the needs of the family, and with input from other professionals as necessary.

There are several programmes (such as the MEHRIT program and the Play and Language for Autistic Youngsters (PLAY) Project Home Consultation program) which are based on the DIR Method. There are also a number of other multi-component programmes (such as the Children's Toddler School Program in the US) which incorporate elements of the DIR Method alongside elements from other approaches.

Our Opinion

There is some very limited research evidence to suggest that the DIR method may help improve the quality of interactions between some young children on the autism spectrum and their parents.

There is insufficient research evidence to determine if the DIR method provides any kind of other benefits to children on the autism spectrum or their parents.

Future research should use randomised controlled designs to investigate the effectiveness of the DIR Method against active control groups (for example, by directly comparing the DIR Method with other interventions, relative to a no-treatment control group) using larger sample sizes.

It would also be helpful to identify the effectiveness of the specific components of the DIR Method, investigating whether and how these add value to the programme.

Disclaimer

Please read our Disclaimer on Autism Interventions


Audience

The DIR method was originally designed for infants, toddlers and preschoolers with developmental disorders including autism but it can also be used with a range of other children.  For example, according to The Interdisciplinary Council on Development and Learning website, accessed on 8 March 2016,   

“While the DIR model helps us understand and promote the positive development of all children, DIR and DIRFloortime are most commonly utilized with children with educational, social-emotional, mental health, and/or developmental challenges. DIRFloortime has become most widely known as an approach to support children with Autism Spectrum Disorders (ASD). “

Aims and Claims

Aims

According to The Interdisciplinary Council on Development and Learning website, accessed on 8 March 2016,  

“The DIR model is ... a framework that helps clinicians, parents and educators conduct comprehensive assessments and develop educational and/or intervention programs tailored to the unique challenges and strengths of each child.”

“The objectives of the DIR® Model are to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviors.”

“Six basic developmental levels (AKA: stages, milestones, or capacities) lay a foundation for all our learning and development.”

“These six basic steps form a developmental ladder; each layers new abilities onto those of prior stages. We identify each of these steps because each one marks a major turning point in the life of a child.”

The six basic steps are

  • Level 1: Self-regulation and interest in the world
  •  Level 2: Intimacy, engagement, and falling in love
  • Level 3: Two-way communication
  • Level 4: Complex communication
  • Level 5: Emotional ideas
  • Level 6: Emotional and logical thinking

Claims

There have been various claims made for the DIR Method.  For example, The Interdisciplinary Council on Development and Learning website, accessed on 8 March 2016, claims that,

“DIRFloortime has the strongest research of any intervention to support its effectiveness in improving the core challenges of autism including relating, interacting, and communicating while decreasing caregiver stress and improving parent-child relationships.”

The website cites various research studies to support this claim.  For example, it reports

 “Four randomized-controlled studies were published since 2011 identifying statistically significant improvement in children with autism who used Floortime versus traditional behavioral approaches (Solomon, et. al., 2014; Casenheiser, Shanker and Steiben, 2011; Lal and Chhabria, 2013; Pajareya and Kopmaneejumruslers, 2011). These studies also showed the effectiveness of addressing the caregiver (Casenheiser et. al., 2011; Solomon, et. al., 2014) and specific skill improvement including turn taking, two way communication, understanding cause and effect and emotional thinking (Lal and Chhabria, 2013).”

Key Features

The DIR Method (also known as Floortime, DIRFloortime or the Developmental, Individual Difference, Relationship-Based Model) is a comprehensive, multi-component intervention used to help children with autism and other developmental disabilities.

The DIR Method is based on the idea that some children have difficulty reaching certain developmental milestones (such as two-way communication) and can be helped to meet those milestones through playful, structured interaction with an adult.

The DIR method allows carers to use a wide range of techniques and other interventions – such as speech and language therapy – alongside the core element of ‘Floortime’.

There are several programmes (such as the MEHRIT program and the Play and Language for Autistic Youngsters (PLAY) Project Home Consultation program) which are based on the DIR Method. There are also a number of other multi-component programmes (such as the Children's Toddler School Program in the US) which incorporate elements of the DIR Method alongside elements from other approaches.

Floortime

‘Floortime’ is a series of interactive exercises that are designed to help the child master key developmental milestones. As the name suggests, most of the exercises take place on the floor.

The carer follows the child's lead and plays at whatever captures his interest but does so in way that encourages the child to interact with the carer. The role of the carer is to be a constructive helper and, when necessary, provocateur by doing whatever it takes to turn the child’s activity into a two-person interaction.

For example, if the child wants to roll cars, the carer rolls cars with him, offering him a faster car or a competitive race or, if necessary, crashing his car with the carer’s – whatever it takes to create an interaction.

By creating these interactions, over and over again, the carer builds on and develops the child’s interests and capabilities until the child is enticed into the world of ideas and logical thinking.

Floortime exercises

The exercises are based around five key steps.

  • Step 1. Observation

The partner listens to and watches the child to determine how best to approach him or her.

  • Step 2. Approach – open circles of communication

The partner approaches the child using appropriate words and gestures based on his or her mood and communication/behaviour style.

  • Step 3. Follow the child’s lead

The child establishes the tone, guides the activity and creates ‘personal dramas.’ This helps the child experience feelings of warmth, connectedness and being understood by the partner.

  • Step 4. Extend and expand play

The partner makes encouraging comments about the child’s play. This helps the child to express ideas and emotions.

  • Step 5. Child closes the circle of communication

The child makes comments and gestures of his or her own.

Cost and Time

Cost

The costs of using the DIR method will depend to a large extent on the needs of the child, whether professionals provide any kind of support, and whether any training or support materials are purchased.

- Specific programmes

The study by Solomon et al (2104) suggested that the average cost of the Play and Language for Autistic Youngsters (PLAY) Project Home Consultation program – which involves speech and language therapists, occupational therapists and educators - is now between $3500 and $4500 per year per child. 

- Training

The Interdisciplinary Council on Development and Learning website, accessed on 8 March 2016, lists a number of training programmes aimed at parents and professionals including

  • DIR 101: An Introduction to DIR and DIRFloortime:  Professionals $169(live online) and $199(onsite) Parents of Children with Special Needs, Self-Advocates, and College Students: $109 (prices vary)
  • DIR 201: Promoting Basic Functional Emotional Developmental Capacities; Standard Pricing:  $699 (prices vary)
  • DIR 202: Promoting Higher Functional Emotional Developmental Capacities. Standard Pricing:  $789 (prices vary)
  • DIR 204B: Becoming an Expert DIRFloortime Provider: Standard Pricing: $599 (prices vary)

Time

The length and frequency of the intervention will depend on the specific needs of the child.  For example, according to The Interdisciplinary Council on Development and Learning website, accessed on 8 March 2016,

“A comprehensive approach comprises many elements, but the cornerstone is the home Floortime program. For the more severe and challenging problems, six to ten 20 to 30 minute Floortime sessions every day is optimal.”

Risks and Safety

Hazards

There are no known hazards for the DIR method.

Contraindications

There are no known contraindications (something which makes a particular treatment or procedure potentially inadvisable) for the DIR method.

Suppliers and Availability

Suppliers

The main providers of the DIR method are the parents and other informal carers who undertake the Floortime exercises. They do not need any formal qualifications, although most will have studied the materials published by the Interdisciplinary Council on Development and Learning or attended one or more of their courses.

The other providers may include a range of professionals, such as speech and language therapists, occupational therapists and educators.

Credentials

In theory, any parent or carer can implement the DIR method for themselves, once they have bought and read relevant training materials or attended relevant training courses provided by the Interdisciplinary Council on Development and Learning.

Professionals, such as speech and language therapists, occupational therapists and educators, will have a range of different credentials and qualifications.

The Interdisciplinary Council on Developmental and Learning website also provides details of approved clinicians who can provide assistance with the DIR method within the USA and some other countries.

History

The DIR method was developed by Stanley Greenspan and Serena Wieder from the school of Psychiatry and Pediatrics at George Washington University Medical School during the 1990s.

Greenspan and Wieder went on to found and run two organisations in 2003 to promote the DIR model. The Interdisciplinary Council on Developmental & Learning Disorders provides educational programs and training materials to professionals. The Floortime Foundation provides outreach and training for parents and other non-professionals.

Current Research

We have identified twelve scientific studies of the DIR method as an intervention for children on the autism spectrum published in peer-reviewed journals published in English.

These studies included more than 300 participants aged between 2 and 6 years old and included children with autism, autistic disorder and pervasive developmental disorder - not otherwise specified.

  • Some of the studies (such as Casenhiser et al, 2013; Dionne and Martini, 2011; Liao et al, 2014; Solomon et al, 2007; Solomon et al, 2014) reported increased social interaction and communication between the children and parents
  • Some of the studies  (Liao et al, 2004; Pajareya  and Nopmaneejumruslers, 2011) reported improvements across a  range of areas, such as emotional functioning  and/or daily living skills
  • One of the studies (Sealy and Glovinsky, 2016) reported increased parental reflective functioning

One of the studies (Hilton and Seal, 2007) reported that the DIR method was slightly less effective than discrete trial training in the case of the two twin brothers studied.

- Studies not included

Please note:  we have identified a number of studies which we did not include in our evaluation for a variety of reasons

A study by Wieder and Greenspan, 2005 appeared in the Journal of Developmental and Learning Disorders, which is published by The Interdisciplinary Council on Development and Learning, Inc.. The latter is an organisation specifically set up to promote the DIR Method. We therefore do not consider this study to be sufficiently independent for us to draw any meaningful conclusions.There are a number of other studies which do not appear to include any participants on the autism spectrum or which were not published in peer-reviewed journals and we have not included these.

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."

Ongoing Research

This page provides details of ongoing research into the DIR method and people on the autism spectrum.

If you know of any other trials we should include please email info@researchautism.net with the details. Thank you.

Future Research

Summary of Existing Research

There is some very limited research evidence to suggest that the DIR method may help improve the quality of interactions between some young children on the autism spectrum and their parents.

There is insufficient research evidence to determine if the DIR method provides any other benefits to children on the autism spectrum or their parents.

Recommendations for Future Research

Future research should use randomised controlled designs to investigate the effectiveness of the DIR Method against active control groups (for example, by directly comparing the DIR Method with other interventions, relative to a no-treatment control group) using larger sample sizes.

It would also be helpful to identify the effectiveness of the specific components of the DIR Method, investigating whether and how these add value to the programme.

Studies and Trials

This section provides details of scientific studies into the effectiveness of this intervention for people with autism which have been published in English-language, peer-reviewed journals. If you know of any other studies we should include please email info@researchautism.net with the details. Thank you.

If you are a UK resident you may be able to obtain full copies of some of the items listed here from your local public library, your college library, or the National Autistic Society's Information. Centre. You may also be able to obtain copies from the publisher of the items.

Other Reading

This section provides details of other publications on this topic. If you know of any other publications we should include please email info@researchautism.net with the details. Thank you.

Please note that Research Autism is unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Additional Information

What does DIR mean?

  • The D (Developmental) part of the Model describes the building blocks of this foundation. Understanding where the child is developmentally is critical to planning a treatment program.
  • The I (Individual differences) part of the Model describes the unique biologically-based ways each child takes in, regulates, responds to, and comprehends sensations such as sound, touch, and the planning and sequencing of actions and ideas
  • The R (Relationship-based) part of the Model describes the learning relationships with caregivers, educators, therapists, peers, and others who tailor their affect based interactions to the child’s individual differences and developmental capacities to enable progress in mastering the essential foundations.

 

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