Sunteți pe pagina 1din 9

Pacific University

CommonKnowledge
Pediatrics CATs OT Critically Appraised Topics

1-1-2008

The DIR/floortime model and its implementation and use for intervention with children with ASD/ PDD
Krissy Anderson
Pacific University

Notice to Readers
This work is not a peer-reviewed publication. Though the author of this work has provided a summary of the best available evidence at the time of writing, readers are encouraged to use this CAT as a starting point for further reading and investigation, rather than as a definitive answer to the clinical question posed or as a substitute for clinical decision-making. Select copyrighted material from published articles may be included in this CAT for the purpose of providing a context for an informed critical appraisal. Readers are strongly encouraged to seek out the published articles included here for additional information and to further examine the findings in their original presentation. Copyrighted materials from articles included in this CAT should not be re-used without the copyright holder's permission.

Recommended Citation
Anderson, Krissy, "The DIR/floortime model and its implementation and use for intervention with children with ASD/PDD" (2008). Pediatrics CATs. Paper 4. http://commons.pacificu.edu/otpeds/4

This is brought to you for free and open access by the OT Critically Appraised Topics at CommonKnowledge. It has been accepted for inclusion in Pediatrics CATs by an authorized administrator of CommonKnowledge. For more information, please contact gilmani@pacificu.edu.

The DIR/floortime model and its implementation and use for intervention with children with ASD/PDD
Disciplines

Occupational Therapy | Pediatrics | Rehabilitation and Therapy


Rights

Terms of use for work posted in CommonKnowledge.

This is available at CommonKnowledge: http://commons.pacificu.edu/otpeds/4

CriticallyAppraisedTopic

Preparedby: KrissyAnderson OT533 December2008

ClinicalScenario: AutismSpectrumDisorders(ASD)arethesecondmostcommondevelopmentaldisabilityinchildren inAmerica,withonein150childrenbeingdiagnosed(CDC,2007).ASD,aswellasPervasiveDevelopmental Disorder(PDD),diagnosesareclearlyontheriseandtherefore,agrowingnumberofchildrenareinneedof specializedservices.WiththehighcostsofservicesandincreasednumberofASD/PDDdiagnoses,itis imperativethatweknowthebesttreatmentandinterventionstrategies;allwhilesupportingcosteffective programs. FloortimeortheDevelopmental,IndividualDifferences,RelationshipBased(DIR)approach,isan individualizedapproachtotreatingchildrenwithASD/PDD.Itfocusesonthechildscorefunctional emotionalandsocialcapacitiesateachstageinhisorherdevelopment,aswellashisorherindividual processingdifferencesandrelationshippatterns(Greenspan&Wieder,2001).Thereisagrowinginterest anduseofthisapproachinmanyareasofpractice,includingOccupationalTherapy,thattreatchildrenwith ASD/PDD. AsaprofessionthatassessesandtreatschildrenwithASD/PDD,OccupationalTherapistsarevery interestedinthefloortime/DIRapproach.Ifthistreatmentisproventobeeffective,itmaybeconsideredan evidencebasedapproach.Furthermore,withextensiveresearch,thefloortime/DIRapproachmaybe consideredthebestpracticeapproachwhentreatingthispopulation.

FocusedClinicalQuestion: Whatisknownaboutthefloortime/DIRapproachfortreatingchildrenwithASDandPDDandhowisitused andimplementedinpractice?


ClinicalBottomLine: Thereisinsufficientevidencetosupportthefloortime/DIRapproachasatreatmentintervention,andmore researchneedstobedone.However,currentresearchandevidenceshowsthatthefloortime/DIRapproach may be as or more effective than other pediatric interventions for Autism Spectrum Disorders (ASD) and PervasiveDevelopmentDisorders(PDD).

LimitationofthisCAT: Thiscriticallyappraisedpaperhasnotbeenexternallypeerreviewed,andthereviewerisinexperienced. Therearealsoalimitednumberofstudiesavailableforreview,andonlyfivestudieswereused.

Summaryofsearch&keyfindings: LevelI:Noarticles LevelII:Noarticles LevelIII: (Solomon,Necheles,Ferch,&Bruchman,2007) Thiswasapre/poststudyexploringtheeffectivenessofalowcostprogram(thePLAYProject)that incorporatesfloortime/DIRprinciples.ItincludedyoungchildrenwithASD(n=68)andfocusedontraining theirparents/caregiverstousefloortimewiththeirchildrenonadailybasis.Thereweremanylimitationsto thisstudy,makingitimpossibletoprovethatthePLAYProjectaloneishighlyeffective. ThestudyconcludedthatwiththehighprevalenceofASDandthehighcostsofservicesbytrained professionals,morerigorousstudiesareurgentlyneededtoestablishtheclinicalandcosteffectivenessof thistypeofplaybasedintervention. LevelIV: (Greenspan&Wieder,2005) ThiswasafollowupstudyofGreenspan&Wieders200chartreviewstudy(1997).Theresearcherswere interestedinwhetherasubgroup(n=16)ofchildrendiagnosedwithASDcouldlearntoberelated, empathetic,creative,reflectivethinkers.ThisstudyconcludedthatchildrenwithASDcancontinueto developmentallyprogressthroughadolescentyearsandbeyond.Thereforeitisimportanttoworkwith familiesandtheirchildrenonrelating,communicating,andthinking,atayoungageandonward.Althoughit isnottypicalofallkidswithASD,all16childreninthisfollowupstudybecamewarm,related,andsensitive youngpeoplewithanoptimisticfuture. (Greenspan&Wieder,2003) Thepurposeofthiscasestudywastoshowtheeffectivenessoffloortime/DIRapproachwithoneboy diagnosedwithautism.Thestudyfollowedtheyoungboyoverthecourseofthreeyears.Itwasconcluded thatfloortimewascentraltotheboysprogress,inthathelpedhimbuildthestructurenecessaryforeach successivetreatment.Theresearchersobservationssuggestthatinteractiveplayprovidedthelifelineforthe boysdevelopment.However,outcomesofthiscasestudyarenotgeneralizabletobroaderpopulations.This boywasalsoreceivingothertreatmentsthatwerenotcontrolledfor. (Greenspan&Wieder,1997) Thisstudyreviewedthechartsof200childrenwithASDtohelpunderstandearlydiagnosisandwhat treatmentiseffectiveforthesechildren.Thisstudyconcludedthatanumberofintensivetreatmentsappear tobehelpful,butitisimportanttobeawarethatdifferentchildrenmayrespondtointerventionsdifferently, soweneedtoknowwhatcharacteristicsshouldbepairedwithwhatinterventions.Itwasalsodetermined thatmoreresearchneedstobedone. LevelV: (Greenspan&Wieder,2001) This article was an overview of the floortime/DIR Approach. It focused on assessment and intervention planning. It explained that interventions for children with autism often fail because the many factors surrounding a child, their parents, and the environment are not always taken into consideration. InterventionsforchildrenwithASDshouldbeuniquetoeachperson,andfloortimeisanapproachthattakes thewholeperson,environment,andoccupation(play),intoconsideration.

SearchStrategies
Categories KeySearchTerms Children,infants,toddlers,pediatrics,AutismSpectrumDisorder,ASD,Pervasive DevelopmentDisorder(PDD) DIR(alsodevelopmental,interactive,relationshipbased),floortime,interactiveplay none Communication,developmentallevels

Patient/Client Intervention Comparison Outcome(s) Databasesandsitessearched MedlineOVID CINAHL ERICEbscoHost MDConsult OTcats.com GoogleScholar.com Google.com Floortime.org

SearchTerms Floortime,DIR,Developmental,Individual Differences,Relationshipbasedapproach, Autism+children,Floortime,Floortime,& InteractivePlay,StanleyGreenspan DIR,Floortime,EngagingAutism:Usingthe FloortimeApproachtoHelpChildrenRelate, CommunicateandThink(foundarticleon googlescholarbutcouldntgetaccess), Developmental,IndividualDifferences, Relationshipbasedapproach DevelopmentalPatternsandOutcomesin InfantsandChildrenwithDisordersin RelatingandCommunicating,floortime,DIR Floortime,DIR,Developmental,Individual Differences,Relationshipbasedapproach, Autism+children,InteractivePlay GeneralsearchtoviewOTCATtopics StanleyGreenspan,floortime,DIR, Developmental,IndividualDifferences, Relationshipbasedapproach StanleyGreenspan,floortime,DIR, Developmental,IndividualDifferences, Relationshipbasedapproach SearchedthewebsitesProfessionalstab, andviewedarticlessupportingfloortime

LimitsUsed Inclusioncriteriawasthatfloor timewasthemain intervention/treatmentused Articlesusinginteractiveplay, butnotcallingitfloortimeor DIRwereexcluded. Articleswerenotlimitedto contextofOccupational Therapy Allsearcheswerelimitedtothe Englishlanguage. Therewasnolimitplacedon thedatesofarticles.

ResultsofSearch FiverelevantstudieswerelocatedandcategorizedasshowninTable1. Table1.SummaryofStudyDesignsofArticlesRetrieved LevelofEvidence I II III IV V


StudyDesign Systematicreviews,metaanalyses,randomizedcontroltrials Twogroups,nonrandomizedstudies(e.g.cohort,case control) Onegroup,nonrandomized(e.g.beforeandafter,pretest posttest) Descriptivestudiesthatincludeanalysisofoutcomes(single subjectdesign,caseseries) Casereportsandexpertopinion,whichincludenarrative literaturereviewsandconsensusstatements QualitativeStudies

NumberLocated 0 0 1 3 1 0 Total=5

BestEvidence Thefollowingarticlewasidentifiedasthebestevidenceandselectedforcriticalappraisal: SolomonR.,NechelesJ.,FerchC.,&BruckmanD.(2007).Pilotstudyofaparenttrainingprogramforyoung childrenwithautism:Theplayprojecthomeconsultationprogram.Autism11(3),205224. Reasonsforselectingthispaperwere: Itencompassesthehighestlevelofevidencethathasbeenpublished(LevelIII) ItistheonlyarticlenotwrittenbyStanleyGreenspan(thecreatoroftheDIRapproach),therefore eliminatinganybiaseshemayhave. Itisthemostrecent(2007)researchstudyonfloortime/DIRapproach.


SummaryofBestEvidence AimofStudy: ThereisagrowingbodyofevidenceshowingthatyoungchildrenwithASDdiagnosesbenefitgreatlyfrom comprehensiveandintensivetherapies;however,theseprogramsareoftenveryexpensive.Thisstudy explorestheeffectivenessofthePLAYProject,alowercostprogramwhichincorporatesfloortime/DIR concepts. InterventionInvestigated: Threepeople(oneMSW,threeRTs)weretrainedinthePLAYProject.Thesethreeactedasconsultantsto the68families.Theseconsultantsmademonthlyvisitstothefamilieshomestoteachthefamilieshowto provideintensive,oneonone,playbasedservices(floortime)totheirchildren.Akeycomponentwas reviewingvideotapesofthechildrenwiththefamilytoshowprogress.Parentsarealsogivenatraining manualandattendaonedaytrainingworkshop.Theoncemonthlyconsultationsfocusonmodeling, coaching,videoassessments,andwrittenobjectives. OutcomeMeasures: FunctionalEmotionalAssessmentScale(FEAS)ratings,subjective6pointratingscale,satisfactionsurvey (likertscale),assessmentandinterpretationofdailylogs. Results: TherewerenochangesintheparentsFEASscoresfrompre/postmeasurements(score=86;p=0.63). Therewasanincreaseinthechildrenstotalandscaledscoresthough(p0.0001).45.5%ofthechildren madegoodtoverygoodfunctionaldevelopmentalprogress;twotailedpairedttestswereused.Therewas anassociationbetweenfewerhours/weekofinterventionandloweroutcomescores,butnosignificant relationshipwasfound(p=0.09,twotailedpairedtestswereused).Highreliabilitywasfound(p0.05, twotailedttest)ininterraterreliability.70%oftheparentswereverysatisfiedwiththePLAYProject. OriginalAuthorsConclusions: ThisstudyconcludedthatwiththehighprevalenceofASDandotherdiagnoses,andthehighcostsofservices bytrainedprofessionals,morerigorousstudiesareurgentlyneededtoestablishtheclinicalandcost effectivenessofthistypeoflowcost,playbasedintervention.Limitationsincluded:nothavingacontrol group,notknowingwhichismoreimportant(parentinteractiontimevs.parentaltraining),almostall childrenbeingenrolledinsomesortofspecialeducationprogram(althoughnotintensiveABA,SI,etc), parentsstresslevelsneededtoberecorded,parentsadherencetodailylogneedstobeimproved,and gainsthatchildrenmadewerenotcomparedtoabilitytomakethesegainsinotherenvironments.

CriticalAppraisal Validity Thisarticlehadextensivebackgroundinformation,justifyingtheneedforthenotonlythePLAYProject,but fortheresearchthatneedstobedoneinaccordance.ThePLAYProjectwasaprogramthatwaswell representativeoffloortime/DIRconcepts.Theprofessionalsfacilitatingthisprojectwerewelltrainedin floortimeandDIRtheories.Overallsamplesizewaslarge(n=68),howevernotrandomized.Therewas approximatelyequalrepresentationofmild,moderate,andseveredisabilities,butboyswereover represented4:1.Thestudystreatmentwasgiveninareasonableandaccommodatingmanner;parental satisfactionwiththePLAYProjectwas90%.Manyofthechildrenwereenrolledinspecialeducation, importantlyhowevernonewerereceivingotherintensivetreatments.Therewasalackofobjective measurementsused,reducingtheamountofoutcomemeasurements,alongwithotherlimitations(see above:conclusions). Results ParentsandchildrenwereratedusingtheFunctionalEmotionalAssessmentScale(FEAS)preandpost intervention.Parentsshowednochange(p=0.63),howeverchildrenshowedanincreaseintotalandscaled FEASscores(p0.0001),and45%ofchildrenmadegoodtoverygoodprogress.Researchersfoundan associationbetweenfewerhoursperweekofinterventionandloweroutcomescore,althoughnot statisticallysignificant(p=0.09).Overall,thisstudysuggeststhatthemodelhasthepotentialtobeacost effectiveinterventionforchildrenwithASDandPDD.
Articleselectedforappraisal: SolomonR.,NechelesJ.,FerchC.,&BruckmanD.(2007).Pilotstudyofaparenttrainingprogramforyoung childrenwithautism:Theplayprojecthomeconsultationprogram.Autism11(3),205224. RelatedArticles: Greenspan,S.I.&Wieder,S.(2005).Canchildrenwithautismmasterthecoredeficitsandbecome empathetic,creative,andreflective?Atentofifteenyearfollowupofasubgroupofchildrenwith autismspectrumdisorders(asd)whoreceivedacomprehensivedevelopmental,individual difference,relationshipbased(dir)approach.TheJournalofDevelopmentalandLearningDisorders. 9,3961. Greenspan,S.I.&Wieder,S.(2003).Climbingthesymbolicladderinthedirmodelthrough floortime/interactiveplay.Autism7(4),425435. Greenspan,S.I.&Wieder,S.(1997).Developmentalpatternsandoutcomesininfantsandchildrenwith disordersinrelatingandcommunicating:Achartreviewof200casesofchildrenwithautism spectrumdiagnoses.JournalofDevelopmentalandLearningDisorders.1,87141. Greenspan,S.I.&Wieder,S.(2001).TheDIR(developmental,individualdifference,relationshipbased) approachtoassessmentandinterventionplanning.ZerotoThree.21(4),1119.

References CentersforDiseaseControlandPrevention(CDC),(2008,January30).Autisminformation center.RetrievedNovember12,2008,fromDepartmentofHealthandHumanServices Website:http://www.cdc.gov/ncbddd/autism/faq_prevalence.htm