Research Article

Research on Social Work Practice

1-11
Examining DIR/Floortime™ as a Treatment ª The Author(s) 2015
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for Children With Autism Spectrum DOI: 10.1177/1049731515583062
rsw.sagepub.com
Disorders: A Review of Research
and Theory

Jean Mercer1

Abstract
Purpose: To review and assess theory and research supporting DIR/Floortime™, a method proposed for treatment of young
children with autism spectrum disorders (ASD). Methods: Published materials describing the principles of DIR/Floortime™ were
evaluated. Published outcome research articles were assessed for the adequacy of their design and implementation and the extent
to which their conclusions were supported. Results: The theoretical basis of DIR/Floortime™ appears to be generally plausible.
Of the 10 outcome research articles in print, all concluding that DIR™ effectively treated ASD, five provided a comparison group,
or used a randomized design, or did both. These studies failed to equalize the duration and frequency of DIR™ and the com-
parison treatment. Conclusions: DIR™ can be considered by social work practitioners as a possibility for evidence-based
practice (EBP), but not as an evidence-based treatment (EBT). Further outcome research needs to concentrate not only on
randomized design but on other design issues.

Keywords
autism, child psychotherapy, DIR/Floortime™, evidence-based treatment

Treatment of autism spectrum disorders (ASDs) in the United carried out by the nonprofit Interdisciplinary Council on Devel-
States has for many years focused on applied behavior analysis opment and Learning (ICDL; www.icdl.com). ICDL offers
(ABA) and related discrete trial methods of modifying beha- coursework in DIR/Floortime™ and certification in the tech-
vior such as the Early Start Denver Model. Because of outcome nique and has developed clinical practice guidelines. ICDL has
research supporting these approaches, public schools have published the Journal of Developmental and Learning Disor-
institutionalized the use of behavioral treatments and public ders since 2001. A second nonprofit organization, the Profec-
funds support them. The present article will consider the claims tum Foundation (www.profectum.org), presents DIR-related
of a less known, less chosen treatment for ASD, Developmen- courses and offers certificate courses at several levels. DIR,
tal, Individual-difference, Relationship-based therapy (DIR), Floortime™, and DIR/Floortime™ are all trademarked terms,
an approach whose implementation is called Floortime™ or and ICDL’s website states that only ICDL gives an official DIR
DIR/Floortime™. Although ABA will occasionally be men- training certificate, adding that organizations that use these
tioned as a part of usual care to which DIR™ methods have terms without ICDL approval may be acting illegally and with-
been compared, this article does not attempt an assessment of out guarantees of the quality of their training. The ICDL site
the relative effectiveness of the two methods. Because there also states that DIR/Floortime™ ‘‘has the strongest research
have been only a small number of research publications on this of any intervention to support its effectiveness in improving the
intervention, this article does not present a systematic review, core challenges of autism including relating, interacting, and
but instead describes the nature and background of DIR/Floor- communicating while decreasing caregiver stress and improv-
time™ and assesses the intervention’s plausibility and existing ing parent-child relationships . . . The research includes the
research support. highest levels of evidence’’ (‘‘Research & Evidence,’’ n.d.).
DIR was developed by the U.S. child psychiatrist Stanley
Greenspan (1941–2010) and his colleagues, the occupational
1
therapist Georgia DeGangi and the clinical psychologist Serena Stockton University, Moorestown, NJ, USA
Wieder, among others. The work of this group was dominated
Corresponding Author:
originally by theoretical and clinical publications (e.g., Green- Jean Mercer, Stockton University, Galloway NJ. Mailing address: 134 E. Main St.,
span, 1992), and outcome research on DIR emerged only fairly Moorestown, NJ 08057.
recently. Dissemination and support of DIR work has been Email: jean.mercer@stockton.edu
2 Research on Social Work Practice

The degree of commercialization of DIR outlined in the pre- the rest of the animate world, but may end with autistic
vious paragraph was unheard of until about 20 years ago, but patterns such as lack of or shallow and impersonal involve-
since that time it has become more common for child psy- ment with the animate world, if the caregiver is emotion-
chotherapies to be trademarked or registered, for ‘‘official’’ ally distant or aloof.
certificates of training to be offered, and for training to be done 3. The stage of somatopsychological differentiation typically
through freestanding organizations dedicated to a particular occurs between 3 and 10 months of age. Ideally, the out-
proprietary intervention. When commercialization takes place, come is the infant’s capacity for flexible, multisystem,
questions can be raised about the evidence that a treatment is affective reciprocal interactions with primary caregivers,
effective (Rosen & Davison, 2003). The present article but poor outcomes include random or chaotic behavior and
describes the theory and practice of DIR/Floortime™ and affect, or narrow, rigid, and stereotyped responses to oth-
addresses the plausibility of, and evidentiary support for, the ers, caused when the caregiver is overly intrusive, preoccu-
treatment. The discussion will include the adjuvant treatments pied, or distressed and thus ignores or misreads infant
often recommended as part of DIR/Floortime™ but less often communications.
considered in terms of the evidence for their effectiveness. In 4. The stage of behavioral organization, initiative, and inter-
light of this information, the description of DIR/Floortime™ nalization typically occurs between 9 and 24 months and
as an alternative treatment (Kurtz, 2008) will be discussed. ideally results in behavior and emotional patterns that are
complex, organized, and integrated as well as assertive and
innovative. Poor outcomes involve withdrawn, compliant,
What Is DIR/Floortime™? hyperaggressive, or disorganized behavior, with stereo-
typed and polarized behavior and emotion, and occur when
DIR is one of a number of Developmental Social Pragmatic
caregiving is overly intrusive or controlling and fearful of
(DSP) treatments for ASD. As Casenhiser, Shanker, and
the toddler’s autonomy.
Stieben (2013) describe DSPs, ‘‘they seek to teach children
5. The stage of representational capacity, differentiation, and
functional skills in a sequence that is generally consistent with
consolidation typically occurs between 1½ and 4 years of
typical child development. . . . they focus on helping children
age. Ideally, this stage culminates in the ability to use inter-
to develop various capacities related to social communication
nal representation and to organize imagery, resulting in
in a pragmatically appropriate social context rather than target-
stabilization of mood. Poor outcomes involve concreteness
ing the behaviors themselves . . . from a DSP perspective, one
of behavior and affect, poor sense of self and others, and
might argue that it is not the behavior of looking in another per-
compromised reality testing, impulse regulation, and mood
son’s eyes that is important, rather, it is the purpose for doing
stabilization.
so’’ (p. 220), for example, understanding another’s intention.
6. Further development from middle childhood through ado-
An important aspect of DIR is a protocol for understanding
lescence is included in Greenspan’s stage scheme, but will
what capacities a child needs to develop, a necessary task given
be omitted here as not strongly relevant to DIR/
the assumption of Casenhiser et al. (2013) that these rather than
Floortime™.
behaviors need to be targeted. Greenspan (1992) described six
steps or stages in early development that were needed in order
for typical development to occur. For each step, he indicated Techniques of DIR/Floortime™
related adaptive capacities and pathologies that might occur
DIR/Floortime™ works toward the achievement of each of the
if a stage did not progress appropriately, as well as examples
early adaptive goals in children who show, by autistic or other
of caregiver behavior that would encourage or discourage
symptoms, that they have not completely achieved adaptive
development of adaptive capacities.
solutions to the tasks of one or more particular phases. Accord-
ing to Lal and Chhahbria (2013), ‘‘Floor time intervention aims
Stages and Goals of DIR at taking the child back to the first milestones that the child may
Greenspan (1992) discussed six stages in early childhood have missed in the process of development’’ (p. 698). In order
development. The typical outcomes of these stages provided to accomplish this, DIR/Floortime™ uses one-to-one interac-
therapeutic goals for working with autistic children. tions between a therapist and a trained parent and carries these
out literally on the floor in a child’s natural play environment.
1. The stage of homeostasis, typically occurring between DIR/Floortime™ begins with the adult’s observation of the
birth and 3 months of age, ideally culminates in internal child and assessment of his or her activities, interests, and emo-
regulation and a balanced interest in the world but may tional state. He or she then approaches the child and joins in
conclude with unregulated or withdrawn behavior (regula- whatever she may be doing, imitating the child’s actions but
tory disorders) if caregivers are unavailable, chaotic, dan- labeling them with words and gestures and expressing interest
gerous, abusive, or dull. and positive affect, thus bidding for communication with the
2. The stage of attachment typically occurs between 2 and child. Whatever the child does, the adult follows the child’s
7 months of age, and ideally results in a rich, deep, multi- lead and supports organization and elaboration of ideas and
sensory emotional investment in primary caregivers and feelings. The adult expands on the child’s play by commenting
Mercer 3

on connections with familiar events. The goal is to achieve choosing the intervention; they are also reminiscent of the
‘‘closed circles of communication’’ or interactions in which the requirements of Lovaas’s, 1987, original ABA study that par-
adult approaches and the child responds, whether by speech, ents take a year off from work to participate in the interven-
gaze, gesture, or movement. Turn-taking would be an impor- tion.) It should be noted, however, that the outcome studies
tant example of closing a circle of communication. to be discussed later in this article apparently did not use in any
How the intervention is actually carried out depends to some systematic way the adjuvant treatments recommended by
extent on what the environment offers. Activities like block- Greenspan.
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 Sources of DIR/Floortime™ Theory and
producing engagement with the adult. Greenspan’s (2001) Practice
‘‘affect diathesis hypothesis’’ states that when interactions with An important starting point for understanding the sources of
adults are pleasurable and contingent on the child’s cues, the DIR/Floortime™ is an examination of Greenspan’s assump-
child’s inherent tendency is to progress through the series of tions about the causes of ASD. Greenspan’s approach acknowl-
increasingly high levels of social competence and to lose pre- edged the probable existence of genetic factors in ASD, but
vious symptoms of autism. Much of the posited effect of looked for other causes as well. ‘‘Immunologic, metabolic, and
DIR/Floortime™ would appear to result from the adult’s ability environmental factors are also believed to play a role. How-
to assess a child’s interests correctly and to make their play ever, no single cause has been definitely shown to produce the
experience engaging and pleasurable (Wieder & Greenspan, disorder. Therefore, we believe the most useful framework for
2003). exploring the underlying causes of ASD is what we call the
The idea of therapy through play and engagement of the cumulative-risk, multiple-pathway model, which recognizes
child raises obvious questions about what is to be done if the that many factors interact to cause the disorder. Genetic or pre-
child does not play or engage. How does one follow the child’s natal factors, for example, may make a child vulnerable to sub-
lead if no lead is given? DIR/Floortime™ practitioners use a sequent challenges including physical stress, infectious illness,
range of actions to move the process along. They do not treat and exposure to toxic substances. This newer way of thinking
the child’s refusal of a bid as rejection of the situation or them- about causation recognizes genetic influences but sees a devel-
selves. They place themselves in front of the child. They may opmental pathway with many steps, a gradual emergence of the
make a ‘‘wrong move’’ so the child will correct what has been associated problems over time, many variations in the prob-
done, do something playfully oppositional in the face of what lems, and varying degrees of severity’’ (Greenspan & Wieder,
the child tries to do (in much the way that caregivers play with 2006, p. 4). Greenspan’s reasoning is thus in agreement with
typically developing infants by offering a toy and then pulling Beaudet’s (2012) suggestion that children at risk for ASD may
it away once or twice while smiling), or ‘‘play dumb’’ so the need different environmental supports than typically develop-
child must explain or indicate what is wanted. They do what the ing children do. However, the rationale does not make clear
child tells them or ‘‘take turns’’ being in charge. They provide why later treatment would reverse problems occurring in the
visual cues to an activity and have ‘‘sensorimotor breaks’’ in course of development or why treatment efforts should attempt
which swinging or other physical actions are encouraged. to repeat experiences that might have been helpful earlier in
A therapist doing DIR/Floortime™ in a child’s home can be life.
seen at www.youtube.com/watch?v¼h3gcpNcq29M. A video Beyond these basic considerations, the foundations of DIR/
of Greenspan directing a family’s interactions with a child is Floortime™ can probably best be discussed in terms of each of
at www.youtube.com/watch?v¼vApghedypFc. the three DIR components: developmental factors, individual
DIR/Floortime™ is not an intervention that can be done in differences, and relationship aspects.
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
Developmental Factors
of DIR/Floortime™—about 15 hours a week—plus a couple of To examine the sources of developmental considerations in
hours a week of speech therapy or other interventions. Green- DIR/Floortime™, we can begin by referencing Greenspan’s
span (1992) recommended daily Floortime sessions with par- (1979) monograph integrating psychoanalytic and Piagetian
ents, two weekly sessions each with speech and occupational theory. This work, entitled Intelligence and adaptation, intro-
therapists, parent counseling once or twice a week, and four duces several important themes in Greenspan’s thinking. The
individual psychotherapy sessions per week. Greenspan com- first point is that both psychoanalytic assumptions about per-
mented that if ‘‘the mother is at home, she can do floor time sonality development and Piagetian theory are stage theories,
three or four times a day. Such a pattern has helped children a characteristic shared by DIR/Floortime™. Such theories pre-
with autistic features become more pleasurably engaged in suppose that success or failure at one stage of development will
two-way communication within six months’’ (1992, p. 699). contribute for good or ill to a later stage and that reworking of
(As has been pointed out elsewhere, the demands of DIR/Floor- early problems (as seen in DIR/Floortime™) may be necessary
time™ may result in a self-selection bias among parents for the solution of later-emerging difficulties. A second point
4 Research on Social Work Practice

revealed by the 1979 monograph is Greenspan’s essential con- Motor tone; 5. Motor planning’’ (1992, p. 14). DeGangi and
nection of emotional and personality factors with intelligence, Greenspan (1989a, 1989b) developed an instrument to assess
shown in DIR/Floortime™ in the proviso that the child’s plea- these characteristics, but the instrument is not mentioned as
surable engagement with a situation is needed in order for having been used to guide treatment in the outcome studies
learning to occur. Third, an essential point of the monograph to be discussed later in this article.
title is ‘‘adaptation’’; development is seen as shaping intelli- Although a considerable literature on infant temperament
gence and behavior to suit an early environment, but the shape existed at the time when Greenspan was formulating DIR/
taken may prove to be either adaptive or maladaptive, as the Floortime™, and might be expected to have been a part of any
child’s environment broadens and presents different demands. individual-difference approach, Greenspan rejected considera-
Greenspan’s view of cognitive development differs from tions of temperament as inferior to assessment of constitu-
Piaget’s and those of other cognitive theorists. Piaget’s tional–maturational individual differences. He noted that
approach posited that cognition develops as a result of the ‘‘temperament research relies on parental reports of the infant’s
inherent processes of assimilation and accommodation, which capacities, rather than ‘hands-on’ assessment of the infant. In
operate on sensory experiences to yield advances in cognitive addition, most temperament constructs tend to assume that
abilities. Rewards or experiences of pleasure are not needed there is a general tendency within the infant toward such global
to stimulate or maintain developmental progress. Similarly, the behaviors as introversion or extraversion, or shyness and inhi-
idea of mastery motivation in young children stresses the bition. In [the DIR] model, these global behavioral tendencies
reward value of mastering any task and the consequent self- are hypothesized to be secondary to highly specific ‘hands-on’
motivation for cognitive and motor development (Yarrow verifiable infant tendencies, such as tactile or auditory
et al., 1983). Greenspan’s view, on the other hand, derives sensitivity or motor tone and motor planning difficulties’’
intellectual development from pleasurable social interaction (1992, p. 23).
experiences. In his opinion, ‘‘affective interactions emerge ear- Greenspan’s interest in individual differences included the
lier than the sensorimotor schemes postulated by Piaget . . . work on regulatory disorders of Porges (Portales, Porges, &
they are the most primary probes we use to understand, concep- Greenspan, 1990). Porges’ work on respiratory sinus arrhyth-
tualize, and ‘double code’ our experiences with the world . . . mia as a factor in good development of young infants suggested
[and] most types of abstract thinking are based on reflections an individual characteristic that could be relevant to develop-
on these personal affective experiences’’ (Greenspan, 2001, ment of regulatory and other disorders.
p. 2). For Greenspan, an infant’s joy and pleasure in a caregiv- Recognizing the level of controversy about food and envi-
ing relationship were necessary before learning could emerge ronmental allergies and sensitivities, Greenspan nevertheless
from interactions within that relationship. This position shares recommended that if such factors were suspected of worsening
some of the tenets of ego psychologists like Heinz Hartmann. 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 prob-
Individual Differences lems and irritability, and noted that ‘‘children with difficulties
The individual-differences aspect of DIR/Floortime™ has dif- with modulating attention, activity, thinking, mood, or beha-
ferent sources than the other aspects. Greenspan’s interest in vior, may benefit from exploration of dietary and environmen-
the contributions of occupational therapy led him to an empha- tal factors’’ (1992, p. 379). As was noted earlier about
sis on individual differences in sensorimotor patterns, as pos- assessment of constitutional–maturational factors, this
ited by the occupational therapist and theorist A. Jean Ayres, approach is not mentioned as part of recent outcome studies.
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
The ‘‘Relationship-Based’’ Component
of young children’s abilities for sensory reactivity and process- Greenspan’s emphasis on DIR/Floortime™ as a relationship-
ing. SIT, often used by occupational therapists, uses adjust- based treatment is seen in his dual focus on child needs and the
ments of sensory stimulation with the intention of altering a appropriate or inappropriate contributions of primary care-
child’s state of arousal and fostering more mature processing givers. The 1992 book discusses the motivation and actions
abilities. Motor tone and motor planning abilities may be of caregivers and notes the importance of their joy in the child
included in this process. Greenspan referred to these child char- and their efforts to draw the child into pleasurable social inter-
acteristics as constitutional–maturational variables and listed actions. This view reflects the work of Bowlby (1982) and oth-
them as follows: ‘‘1. Sensory reactivity, including hypo- and ers on the development of emotional attachment of the child to
hyperreactivity in each sensory modality (tactile, auditory, the parent, but goes beyond Bowlby in consideration of details
visual, vestibular, olfactory); 2. Sensory processing in each of events leading up to attachment. Greenspan referenced
sensory modality (e.g., the ability to decode sequences, config- Margaret Mahler’s and René Spitz’s descriptions of relation-
urations, or abstract patterns); 3. Sensory affective reactivity ship events in early infancy. With respect to motivation, his
and processing in each modality (e.g., the ability to process and emphasis was, like Bowlby’s, on the pleasurable social nature
react to degrees of affective intensity in a stable manner); 4. of interactions that create attachment, rather than on a
Mercer 5

behavioristic view of physical needs and gratifications as they have atypical needs for environmental support, whether
sources of the attachment relationship. dietary or otherwise. The genetics work is congruent with
Greenspan’s view of the importance of relationships gave Greenspan’s emphasis on individual differences as determi-
emphasis to the role of parents as therapists. The power of the nants of appropriate therapeutic approaches. Concepts of tem-
parent–child relationship gave trained and professionally sup- perament (Kagan, 1984), although their measures were rejected
ported parents a therapeutic capacity that allowed them to add by Greenspan as inadequate for DIR purposes, are nevertheless
essential experiences to the various professional treatments congruent with DIR/Floortime™ thinking.
included in DIR/Floortime™. However, whether sensory capacities have the impact on
development claimed by Greenspan is less certain. Ongoing
Other Sources work on auditory capacities, for example, shows that in typi-
cally developing infants the ability to attend selectively to
The play aspect of DIR/Floortime™ resembles other play sounds is more complex than DIR/Floortime™ authors have
approaches in its stress on communication and relationships. assumed (Kidd, Piantadosi, & Aslin, 2012). Given the continu-
Play approaches to therapy involve communication through ing investigation of sensory development, it is questionable
toys, pretending, manipulation of objects, and other nonverbal whether the methods of assessing sensory individual differ-
techniques, as DIR/Floortime™ does. Some play methods, like ences suggested by DeGangi and Greenspan (1989a, 1989b)
Theraplay (Jernberg, 1979), have trained parents to work with can be known to be effective.
children, again with the assumption that the strength of the rela- The relationship-based component of DIR/Floortime™ is
tionship helps to make the play meaningful and therapeutic. 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
Is DIR/Floortime™ a Plausible Treatment? whole body of work on the benefits to development of attach-
The difficulties of establishing a clear evidentiary foundation ment, there is strong support for the importance of relationships
supporting the effectiveness of a treatment for ASD are consid- in the support of development.
erable. As a result, when evidence for a treatment remains In general, then, the foundations of DIR/Floortime™ are
uncertain (a point to be discussed with respect to DIR later in plausible, both logical and congruent with established thinking
this article), it is wise to examine the plausibility of the treat- about early development.
ment—to see whether its arguments are logical and whether its
assumptions are congruent with established information about Adjuvant Methods
early development.
Adjuvant methods recommended by Greenspan (1992) are
rarely mentioned in much detail in current accounts of DIR/
DIR/Floortime™ Treatment Floortime™ outcome studies. Nevertheless, it is reasonable to
The developmental aspects of DIR/Floortime™, discussed ear- examine their plausibility and evidence basis when considering
lier in this article, are plausible in terms of their close agree- DIR/Floortime™. Questions about recommended adjuvant
ment with steps in early development. Of these steps, methods are especially important for outcome research because
attachment is the one that has received by far the greatest atten- of their implications for assurance of treatment fidelity. A later
tion, with thousands of articles published on this topic since section of this article will discuss the adjuvant methods that
Bowlby’s day. Development prior to attachment has presented may be used along with DIR/Floortime™, but the reader should
more challenges to research, and evidence about capacities in keep in mind that the outcome research studies to be discussed
early infancy is still very much under investigation and often in the next section do not necessarily use the same adjuvant
depends on high-technology methods of assessing the rapid methods for each treated child.
behavior changes that can be interpreted as indicating infant
moods or cognitions. As for the later developmental stages con-
Evaluating Evidence for the Effectiveness
sidered by Greenspan and his colleagues, some aspects of con-
tinued attachment development were described by Bowlby, and
of DIR/Floortime™
later work has been directed at negotiation and compromise As an introduction to discussion of evidence for effectiveness
abilities (e.g., Crockenberg, 1992). Nothing in DIR/Floor- of DIR/Floortime™, it may be helpful to look at attitudes about
time™ is at odds with these established ideas and facts about this issue as stated by Cullinane (2015) in a position paper
development. posted on the ICDL website. Cullinane emphasized the inclu-
Consideration of individual differences and their effects on sion in evidence-based practice (EBP) of scientifically rigorous
development has been an important part of the study of early research findings, clinical expertise, and individual characteris-
development. Work on ASD presently includes investigation tics, the last two being important considerations but providing a
of genetic differences as sources of ASD and of differences focus that may be used to minimize the importance of outcome
in the severity of ASD (Beaudet, 2012). Such work has sug- research evidence. After discussing the difficulties of outcome
gested that autistic children may become symptomatic because research on treatments for ASD, Cullinane concluded that
6 Research on Social Work Practice

because ‘‘of the wide range of individual differences in chil- study compared the responses to DIR/Floortime™ of children
dren with ASD, and the many unique relationships within fam- with pervasive developmental disorders to those of children
ilies, it is necessary and proper for parents to have the with developmental delays (Mahoney & Peraqles, 2005). One
information and options necessary to make informed choices (Solomon, Necheles, Ferch, & Bruckman, 2007) used a pre-
about the type of services their child will receive. DIR/Floor- and post-intervention design. All of these studies reported suc-
time™ has a solid base of empirical evidence, and is widely cessful outcomes of DIR/Floortime™ methods, but because of
used for children of all ages and abilities. Evidence based prac- their designs they cannot be considered to give strong support
tice means the clinician can utilize all types of information to the effectiveness of DIR/Floortime™.
including clinical expertise, and a family’s individual values Five investigations mentioned at www.icdl.com/research or
and preferences, in addition to published research. There is elsewhere had designs that provided a comparison/control
ample evidence for the effectiveness of DIR/Floortime™ to group whose outcomes could be compared to those of a treat-
support an informed parent choice’’ (2015, p. 12). This state- ment group, or that randomized families to groups, or that did
ment does not suggest that DIR/Floortime™ groups feel an both. One of these studies (Salt, Sellars, et al., 2001; Salt,
urgent need to provide evidence from high-quality research Shemilt, et al., 2002) was mentioned at www.icdl.com/
to support their methods. Questions thus remain about the research, but although it involves a social-developmental
effectiveness of DIR for treatment of ASD. approach and shared many goals with DIR/Floortime™, this arti-
cle did not mention DIR/Floortime™ or any recognized DIR
advocates, nor were any works focused on DIR included in the
Method Reference section. The small N of the Salt et al. study (14 in the
In order to evaluate the outcomes of treatments with DIR/ treatment group, 5 completing the comparison group work) and
Floortime™, a search of the terms DIR, Floortime™, and the stated absence of randomization also suggest that this study
DIR/Floortime™ was conducted with Academic Search Com- should be omitted from consideration as strong evidence support-
plete, PsycINFO, and PubMed. In addition, publications were ing the effectiveness of DIR/Floortime™ or any related method.
considered if they were named at the webpage www.icdl.-
com/research (‘‘Research & Evidence,’’ n.d.) and described
as evidence supporting the effectiveness of DIR/Floortime™.
Randomized Controlled Studies
No unpublished literature was found through any source, so this A small randomized controlled study by Pajaraya and Nopma-
article is of necessity limited in that it does not include work neejumruslers (2011) compared outcomes for a group of 28
that was not accepted for publication, which might well include preschool children, all of whose families were initially using
studies with negative results. ABA and a mixture of other services, speech therapy, and occu-
Substance Abuse and Mental Health Services Administra- pational therapy, and half of whom were randomized by an
tion’s (SAMHSA’s) National Registry of Evidence-Based Pro- undescribed method to receive DIR/Floortime™ as well as
grams and Practices (www.mrepp.smhsa.gov) does not list the their original community services. The intervention was
treatment under the names DIR, Floortime™, or DIR/Floor- directed entirely at the parents, who did about 15 hours of
time™, nor does the California Evidence-Based Clearinghouse Floortime a week with their children. Significant improvement
for Child Welfare (www.cebc4cw.org). DIR/Floortime™ was was seen in the treatment families, and there were better results
not included in a review of treatments for ASD conducted by when parents did more hours of Floortime, but this difference
the Agency for Healthcare Research and Quality (‘‘Therapies was not statistically significant. An unusual problem with this
for Children with Autism Spectrum Disorder’’, 2011). study was that all materials had to be translated into Thai, and
Evaluation of studies of DIR/Floortime™ would ideally the authors queried whether cultural differences might have
include a discussion of the assessment instruments used in each had an effect.
study, but because such a wide variety of instruments have been Lal and Chhahbria (2013) reported random assignment to
used, this is beyond the scope of the present article. One fre- treatment and control groups of 26 children randomly selected
quently used instrument has been the Functional Emotional from five preschools in Mumbai, but did not elaborate on how
Assessment Scale (DeGangi & Greenspan, 2001), which has either random selection or random assignment to groups was
been reported to be highly reliable for videotaped or live obser- done. The control group was said to receive the usual early
vations, but which does not seem to have been refined by the intervention sessions provided in their educational settings.
further research suggested in the 2001 publication. Because one The treatment group received twenty 30-minute sessions of
of the major concerns about autistic children is language devel- Floortime from therapists and parents. It was not clear whether
opment, a range of speech and language assessments have been the children continued to attend preschool, who administered
included in research on DIR. the assessment and whether that person was blinded to the chil-
Ten systematic investigations of DIR/Floortime™ were dren’s group assignments, or how intervention fidelity was
found as of January 2015. Of these, one (Dionne & Martini, assured. Using a series of t-tests, Lal and Chhabria reported sig-
2011) was a single-subject study. One chart review (Greenspan nificant improvement of the treatment group over the control
& Wieder, 1997) was followed up with a review of a small pro- group for turn-taking, two-way communication, and cause and
portion of the original cases (Wieder & Greenspan, 2005). One effect understanding, but not for emotional thinking.
Mercer 7

Casenhiser et al. (2013) investigated the outcomes of a DIR- Additional limitations of these studies are very difficult to
based intervention, the Canadian Milton and Ethel Harris avoid and emerge from the difficulty of studying families as
Research Initiative treatment program. This article reported they function in their homes. Families dropped out of studies
preliminary data about 51 children from an ongoing larger or changed their practices with their children as a result of
study. The children had been randomly assigned after stratifi- learning what other parents were doing. How many hours were
cation by age and language function to 12 months of DIR- actually spent in Floortime could be known only from parent
like intervention or to 12 months of community treatment reports. Other services received by either the intervention or the
(some combination of speech therapy, ABA, occupational ther- control groups were not necessarily known, and if reported at
apy, social skills group, specialized part-time day care, hyper- the beginning of a study could well have changed by the end.
baric oxygen therapy, and/or specialized diets). In addition to Casenhiser et al. (2013) also noted that in their study there were
Floortime, the DIR-like program stressed coregulation and sen- unavoidable self-selection biases, as the parents involved had
sorimotor supports, using swings and other occupational ther- to be amenable to DIR methods, had to be able to attend train-
apy equipment, lowering or raising sound levels, and ing 2 hours a week, had to be able to complete assignments, and
brightening or dimming lights, to ensure a child’s optimal level had to be able to spend at least 3 hours each day in interactions
of arousal. Four blinded coders assessed videotapes of interac- with one child.
tions. The general quality of social interactions was reported as Given the difficulties of this type of research, it seems rea-
improving significantly in the treatment group, but language sonable to conclude that the existing studies give weak support
did not improve differentially. to the effect of Floortime on some skills of autistic children,
Solomon, van Egeren, Mahoney, Huber, and Zimmerman although improved language functioning is not among these.
(2014) reported on a randomized controlled trial of an interven- However, no independent replications of any of the studies
tion based on DIR, the Play and Language for Autistic Young- have been carried out.
sters (PLAY) project. Computer-generated randomization with
blocks of older and younger children, autism versus autistic Adverse Events
spectrum diagnosis, and gender was used to assign 128 families
either to a PLAY treatment group or to community services No adverse events associated with DIR/Floortime™ have been
(free public preschool special education services and about 2 reported for children or families. Because of Greenspan’s affect
hours a week of private speech therapy). PLAY provided diathesis hypothesis, stating that experiences must be pleasant
coaching, modeling, and video feedback to support 15 hours in order for developmental progress to be caused, there seems
per week of parent work with children in addition to commu- little chance of any direct harm to children, even the ‘‘emo-
nity services for the treatment group. The PLAY group tional burden’’ considered a problem by Linden (2013). It is
received about 600 hours of parent treatment during the year, possible that the demanding schedule of DIR/Floortime™
in addition to about 100 hours of community services, equiva- could be harmful to parents and other children or to family
lent to the community services the other group received. The interests that might be ignored because of the intervention’s
PLAY group was reported to show significant improvement requirements. And, of course, indirect harm can result from
relative to the control group on interaction skills, functional commitment to an ineffective treatment and rejection of more
development, and autistic symptoms, but not on language. effective methods.

Limitations of the Studies Adjuvant Treatments

These studies share a number of limitations. One important Although it is unclear to what extent adjuvant treatments are
point is that they have not systematically compared DIR/Floor- currently used together with DIR/Floortime™, in the interest
time™ to a treatment for which there is clear evidentiary sup- of completeness it seems appropriate to consider the plausibil-
port of effectiveness. The only such treatments are discrete ity of these treatments and the results of research into their
trial methods, and although many of the children in both inter- effectiveness. A systematic review of each is beyond the scope
vention and control groups were having some ABA treatment, of this article. No adverse events have been reported for these
the published reports do not include any information that adjuvant treatments.
enables readers to compare ABA to DIR as might be consid-
ered appropriate, given the empirical support for ABA. A sec-
ond problem is that the studies are designed to compare DIR
Speech Therapy
plus usual services to usual services alone; in other words, each Speech therapy for autistic children was strongly recommended
DIR or DIR-like group receives many more hours of treatment by Greenspan. This is a plausible recommendation in light of
than the control group does, raising the obvious question the speech and language deficits that are often the first indica-
whether any positive effects are simply due to more interaction tion of an autistic pattern of development. With respect to the
with adults rather than with DIR specifics. (This problem is effectiveness of speech therapy, a systematic review (Morgan
present even in the sophisticated and carefully implemented et al., 2014) concluded that speech therapies had ‘‘primarily
Solomon et al., 2014, study.) positive treatment effects on social communication skills’’ of
8 Research on Social Work Practice

autistic children (p. 252), but the review authors cautioned that anticipatory movement (Brisson, Warreyn, Serres, Foussier,
many of the studies had weak designs. & 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 Mer-
SIT cer, 2014, pp. 158–159). However, publications over the last
A second important adjuvant method used when autistic chil- 30 years have repeatedly rejected the idea that SIT is sup-
dren receive DIR/Floortime™ treatment is SIT. This treatment, ported by empirical evidence. Hoehn and Baumeister
generally done by occupational therapists, was recommended (1994) concluded that SIT was demonstrably ineffective. A
by Greenspan as part of therapy for ASD, although it has not 2009 review by Hyatt, Stephenson, and Carter agreed that
been systematically included in outcome research on DIR/ there was no evidence supporting the effectiveness of SIT.
Floortime™. Addison et al. (2012) discussed some of the difficulties of
Sensory integration, as originally defined by Ayres (1964), assessing SIT methods for treatment of feeding disorders and
is a neurological process that organizes sensations from differ- pointed out the need for further investigation.
ent modalities and parts of the body and allows the individual
to use the body within the environment, including in this cate-
gory social interactions with other people. Ayres posited sen-
Developmental Optometry
sory integration and processing disorders, which emerged A current adjuvant treatment used with DIR/Floortime™ by
from a cortical problem with balancing excitation and inhibi- some practitioners is developmental optometry, a method that
tion and achieving a balanced approach to central and periph- claims to alter use of visual information through guided prac-
eral nervous system activity. According to Ayres, such tice and, in conjunction with DIR, to help patients engage with
imbalances were associated with cerebral palsy, attention dis- therapy (Green, Wachs, & Dee, 2014). Although it is unclear
orders, learning disabilities, and ASD. To treat such problems, whether Greenspan himself was in favor of the use of develop-
Ayres (1979) proposed the use of full body movements that mental optometry as an adjuvant treatment with DIR/Floor-
resulted in vestibular, tactile, and proprioceptive stimulation. time™, his colleague Serena Wieder has written a coauthored
She held that this kind of treatment would improve the func- book, published by the Profectum Foundation, asserting the
tioning of the related sense organs. Sensory abilities, and the usefulness of developmental optometry in the treatment of
brain’s ability to organize related sensory information, were autistic children (Wieder & Wachs, 2012). This publication
thought to improve as a result of swinging, balancing, and limb is advertised on the Profectum website. Methods used in devel-
movement. ‘‘Sensory diets’’ also form a part of SIT. As opmental optometry include work on visual tracking, on block
described by Smith, Mruzek, and Mozingo (2005), they may rotations, and on visual sequencing, all in the form of games.
include dimming or brightening of illumination, changes in DIR/Floortime™ methods are used by some practitioners
sound levels, deep pressure techniques, brushing of the skin, (Green et al., 2014) as ways to involve children in developmen-
weighted vests, textured toys, and the wearing of ‘‘body socks’’ tal optometry techniques, with goals of both improved visual/
to provide all-over pressure. spatial capacities and emotional thinking.
SIT techniques are plausible within the context of Ayres’ The claims of developmental optometrists about ASD are
assumptions about disorders and her association of ASD with not plausible in terms of congruence with established informa-
attention disorders and cerebral palsy. If ASD is a special tion. If good vision and visual processing were necessary for
case of difficulty with arousal and attentional control, using emotional or cognitive development, we would find that chil-
environmental changes to adjust arousal would be a logical dren blind or visually impaired from birth were unable to
ploy; if ASD is a different kind of disorder, as genetic studies develop along typical lines of emotional or cognitive achieve-
seem to indicate, it is a mistake to focus on arousal as a focus ment, and this is not the case. However, it is possible that chil-
of treatment, and it becomes difficult to see SIT as a plausible dren genetically inclined to ASD may need different
approach. Ayres’ claim that full-body movements of pre- experiences than genetically typical children in order to attain
school children would improve the functioning of some of more typical development and avoid autistic symptoms
their sense organs is implausible in terms of what is known (Beaudet, 2012), and if this were the case, developmental opto-
about sensory development. Myelination of pathways in the metry for autistic children might be a more plausible approach.
vestibular system is completed very early and unlikely to In addition to these points, the claims that visual exercises can
be affected by later stimulation (Gottlieb, 1971). Even devel- correct major visual problems are implausible in the context of
opment of neural pathways that are slower to myelinate is known events of myelination and of cortical development of
complete by preschool age. In addition to myelination issues, binocular cells; these events, essential to the shaping of visual
the claims of SIT appear unlikely in light of the fact that functions, occur during a critical period, and under no presently
exposure to sensory stimulation generally leads to adaptation known circumstances can they be refashioned when that period
to the stimulus and a lessening of sensitivity. The plausibility is over. The current stress on lasting neurological plasticity, a
of SIT as an adjuvant treatment for DIR/Floortime™ is thus factor in beliefs about developmental optometry, largely
questionable, although in a related area, infants who were ignores the fact that some functions of the nervous system fol-
later diagnosed as autistic did show a lack of age-typical low critical period rules, while others do not; without the as yet
Mercer 9

undeveloped use of hormonal or other chemical treatments to indicates an appropriate pattern for guidance of autistic children.
restore a system to the plasticity of its critical period, changes Assessment of DIR plausibility is thus incomplete.
such as those posited by developmental optometry are quite Outcome research on DIR/Floortime™ has given some sup-
unlikely. port to the effectiveness of the intervention for autistic children,
Problems of individualization and measurement cause diffi- at least for nonlanguage measures, but this support is weak
culties for outcome research on developmental optometry. because of design flaws. Some of these flaws are almost una-
Nevertheless, a review sponsored by the British College of voidable, because parents of children living at home have con-
Optometrists (Barrett, 2009) considered research publications trol over the duration of the treatment they give the children
on this topic and concluded that although specific visual prob- and over additional treatments the children receive. Given par-
lems like amblyopia or convergence disorders could be helped ental choice as a factor in participation, it would be difficult to
by use of orthoptic methods, including prism lenses, most of randomize children to ABA, DIR/Floortime™, or any other
the claims about successful treatment of dyslexia and other intervention. Nonrandomized designs that are carefully
childhood disorders were without adequate foundation. designed and implemented may be the highest level that this
kind of outcome research can achieve.
However difficult randomization and some other aspects of
outcome research on DIR/Floortime™ may be, there are factors
Discussion and Applications to Practice
that can and should be more carefully managed in future work
DIR/Floortime™ methods are not part of social work profes- than they have been in the past. It should be possible to exert
sional education in the sense that they are a part of occupational greater control over the frequency and duration of intervention
therapists’ training, nor does training in such methods play a experienced by treatment and control groups than has been
role in social work licensure. Nonetheless, DIR/Floortime™ done so far. When an intervention group experiences many
is a part of the practice of some social workers. Googling times more hours of treatment than the control group, treatment
‘‘social work DIR’’ brings up documents showing numbers of duration and treatment type are completely confounded, and it
social workers who have trained in DIR/Floortime™ and now is impossible to conclude that specific treatment factors caused
make its methods a part of their therapeutic work. In addition, differences between the groups; some control over durations
social workers may provide important guidance for families of would be necessary to unconfound these factors. It is notable
children with ASD who are trying to understand their options that in outcome research on ABA, a study that involved many
and to make good choices. For both these reasons, it is impor- hours of treatment per week (Lovaas, 1987) showed better out-
tant for social workers to have information about DIR/Floor- comes of the treatment than the one with fewer hours (Smith,
time™ so that they can realistically assess their own work Groen, & Wynn, 2000). A dose–response relationship is plau-
and offer accurate explanations to clients. These tasks can sible for any psychotherapy (Maglione et al., 2012). Further
involve both the plausibility of DIR/Floortime™ and its adju- research on DIR/Floortime™ needs to isolate the treatment
vant treatments, and what is presently known from outcome variable by assuring equal frequency of DIR treatments and
research on these methods. Given practitioners’ clinical expe- that of whatever other treatment is chosen as a ‘‘usual care’’
rience and clients’ preferences, it is possible that even the rel- comparison.
atively weak evidence for DIR could form part of EBP. DIR/ Because of a variety of weaknesses in designs of outcome
Floortime™ methods of treating ASD appear plausible in the studies on the adjuvant treatments sometimes used with DIR,
sense that they are congruent with much that has been estab- it cannot be concluded that these methods are effective treat-
lished or theorized about early development; the adjuvant treat- ments for ASD. Thus, the statement that DIR/Floortime™ has
ments SIT and developmental optometry are much less ‘‘the strongest evidence’’ of effectiveness of all ASD treat-
plausible, and social workers should be aware of these facts. ments (‘‘Research & Evidence,’’ n.d.) does not appear to be
They should also understand that DIR/Floortime™ does not correct at the time this is written. Advocates of DIR/Floor-
have the status of an evidence-based treatment. time™ might do well to delay the commercialization and
With respect to plausibility, there is a question that applies not advertising of the intervention until better evidence has been
only to DIR but also to some other child psychotherapies: Does collected. Given the general factors that DIR/Floortime™
typical development provide a pattern for treatment of atypical shares with other child psychotherapies, however, it is probably
children? If each stage builds on the previous one, as is usually as effective a treatment for ASD as other DSP treatments.
assumed by stage theories, it is important to know whether the Although DIR/Floortime™ has been described as an alternative
sequence must always be the same, whether different develop- psychotherapy (Kurtz, 2008), it appears to be conventional in
mental sequences are possible, and whether, as Erik Erikson practice except for the recommendations of SIT and develop-
(1950) suggested, problems of earlier stages are regularly revis- mental optometry as adjuvant treatments. DIR/Floortime™ has
ited at later points in development. If indeed the typical pattern no known record of adverse events and would seem to have lit-
of development offers a template for intervention, which is often tle potential for direct harm to children, as it involves very little
assumed, but has not been demonstrated empirically, there is still coercive activity. The potential for direct harm is greater for
an unanswered question about the list of normal developmental SIT and developmental optometry because of their physical
milestones provided by Greenspan and whether it necessarily nature.
10 Research on Social Work Practice

DIR/Floortime™ deserves consideration by social work biopsychology of development (pp. 67–128). New York, NY:
practitioners involved with families with a member who has Academic.
ASD, but that consideration must be careful and cognizant that Green, M. D. A., Wachs, H., & Dee, M. (2014). Successful optometric
some of the claims for this intervention are not well supported. vision therapy with patients on the autistic spectrum: Engaging
patients with visual-cognitive therapy. Optometry & Visual Perfor-
Declaration of Conflicting Interests mance, 2, 235–239.
The author declared no potential conflicts of interest with respect to Greenspan, S. I. (1979). Intelligence and adaptation: An integration of
the research, authorship, and/or publication of this article. psychoanalytic and Piagetian developmental psychology. Psycho-
logical Issues Monographs, Nos. 47-48. New York, NY: Interna-
Funding tional Universities Press.
The author received no financial support for the research, authorship, Greenspan, S. I. (1992). Infancy and early childhood: The practice of
and/or publication of this article. clinical assessment and intervention with emotional and develop-
mental challenges. Madison, CT: International Universities
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