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Autism and Developmental Disorders
2023. Vol. 21, no. 4, 26–33
doi:10.17759/autdd.2023210403
ISSN: 1994-1617 / 2413-4317 (online)

Evidence Base Analysis of the Effectiveness of Early Intervention Models: the DIRFloortime Model and the ESDM Model. Part 1. DIRFloortime Model

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N.V. Romanovsky

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Abstract

Objectives. Early intervention for a child with autism spectrum disorder (ASD) produces more effective outcomes than later interventions. A description of the empirically proven algorithms of the DIRFloortime and ESDM (Early Start Denver Model) models of early intervention allows us to assess the extent to which a practical model of early intervention presented in the intervention space is consistent with its empirically proven model. Current research empirically proving the effectiveness of using the DIRFloortime model has been analyzed.

Methods. Twelve English-language and one Russian-language article were used in this work, devoted to the study of the effectiveness of the DIRFloortime model and showing mainly the results of randomized and controlled trials or devoted to their review. The analysis was performed using electronic resources: eLIBRARY.RU, CyberLeninck, PubMed, ReseachGate and others.

Results. The results of the analysis of the cited studies indicate a greater effectiveness of the DIR approach options in working with children with autism spectrum disorders (ASD) compared to standard available care options on such parameters as: reduction of core autism symptoms, improved ability to engage and maintain reciprocal emotional contact, improved joint and divided attention, improved speech, improved child-parent relationships, and reduced symptoms of depression in parents.

Conclusions. Key evidence-based algorithms for applying the DIR model are described, which include: age of onset of care from 24 to 59 months; individualized care plan; regular parent education; independent parent-child interaction for about 2—3 hours per day; and interdisciplinary and teamwork among professionals.

General Information

Keywords: DIRFloortime methodology; autism spectrum disorders (ASD); early intervention; evidence-based ap- proach; parent training; intervention procedure; early intervention effectiveness; intervention intensity

Journal rubric: Research of ASD

Article type: scientific article

DOI: https://doi.org/10.17759/autdd.2023210403

Funding. This study was funded by the State assignment of the Ministry of Education “Institute of Correctional Pedagogy” No. 073-00063-23-01.

Received: 30.10.2023

Accepted:

For citation: Romanovsky N.V. Evidence Base Analysis of the Effectiveness of Early Intervention Models: the DIRFloortime Model and the ESDM Model. Part 1. DIRFloortime Model. Autizm i narusheniya razvitiya = Autism and Developmental Disorders, 2023. Vol. 21, no. 4, pp. 26–33. DOI: 10.17759/autdd.2023210403. (In Russ., аbstr. in Engl.)

Full text

Introduction

 
If we consider early intervention for children with developmental disabilities as a variant of psychological and social practices, an important requirement for it would be the existence of empirical evidence of its effectiveness, obtained in scientific research and presented to the professional community through scientific publications [3].
Such studies are of high practical value because they allow us to evaluate the specific algorithm of practice application and its effect. The very possibility of such an evaluation allows all interested parties to draw a conclusion about the compliance of a practically presented model of early intervention with its empirically verified primary source, which can serve as a basis for making a decision on its inclusion in rehabilitation measures.
The presence of discrepancies between the model practically presented and its original source may be a reason to evaluate it more closely and decide to seek other available options for assistance.
The paper presents an analysis of current research that empirically proves the effectiveness of using the DIRFloortime model.
DIR is an evidence-based therapeutic approach that aims to diagnose and create a relationship-based programme of care that takes into account each child's developmental level, perceptual, motor, emotional and cognitive development. Floortime is the main methodology for implementing the programme, the "target play", and the philosophy behind the approach. The DIRFloortime approach belongs to the so-called socio-pragmatic approaches aimed, among other things, at educating parents [7; 8; 13; 15]. In the DIR approach, the main goal of the intervention is to build the foundations for a healthy development of the child by following all the necessary steps. The acronym DIR stands for three key concepts - Developmental, Individual differences, Relationship. The developmental (D) essence of the concept is expressed in the fact that the approach supports the development of social, emotional and intellectual abilities. At the same time, functional socio-emotional abilities, described by the founder of this approach S. Greenspan in the form of hierarchically organized skills, which are called stages of functional socio-emotional development [4; 5], are of priority importance for the child's development. In total, the author identified about 12 stages, but the first 6 of them are basic and, under the condition of healthy development, are achieved by a child by the age of 5 years. These include: 1. Self-regulation, attention and interest in the world, 2. Contact, communication, attachment, 3. Initiative and two-way communication, 4. Social problem solving and the formation of self-awareness, 5. Symbol formation, use of words and concepts, 6. Emotional thinking, logic and sense of reality. Great importance is attached to individual differences (I), which are understood as such factors affecting the child's development as the ability and speed of information processing, the ability to self-regulate, consideration of the child's sensory and motor characteristics (sensorimotor profile), as well as the characteristics of the family and relationships within it. The DIRFloortime approach broadly integrates the ideas of occupational therapist J. Iris and her theory of sensory integration [1].
The developmental effects of the DIRFloortime approach are relationship-based (R) and use emotionally charged relationships as a developmental engine. The DIR concept is based on J. Bowlby's attachment theory, according to which attachment is a close emotional bond between a child and a parent that is necessary for healthy mental development [2]. In addition to the immediate attachment relationship, the DIRFloortime approach develops the basic stages of social-emotional development in the process of such emotionally rich relationships. From the perspective of this approach, it is possible to help a child overcome developmental difficulties through an emotional relationship with him/her, taking as a starting point his/her current level of development, taking into account his/her individual characteristics, encouraging him/her to develop socially, emotionally and intellectually.
The DIRFloortime model is positioned as an effective early intervention model.
 

Materials and Methods

 
Due to the circumstances outlined, I set out to evaluate the scientific and practical validity of the DIRFloortime early intervention model. The research methods used were theoretical analyses of current research on the evaluation of the effectiveness of the DIRFloortime model, as presented in scientific publications.
The review used studies from the so-called 'gold standard' - randomized controlled trials; however, I have also used data from other studies - those with high practical relevance, as well as systematic reviews of studies - in the analytical review presented.
The analysis was conducted using the following electronic resources: eLIBRARY.RU, CyberLeninka, PubMed, ResearchGate. In addition, printed publications available in Russia devoted to the DIR approach were used [4; 5; 7].
 

Study Results

 
The creator of the DIRFloortime approach, psychiatrist S. Greenspan, conducted a substantial study of the efficacy of the DIRFloortime approach, but because its design was more of a psychiatric study, it lacked a control group, and for this reason the results of this study cannot be fully considered through the lens of an evidence-based approach to evaluating its efficacy. The studies with the most rigorous scientific design are summarized here in chronological order.
In 2007, an article was published by R. Solomon et al. [18], describing a pilot study of a home-based parental education programme within the framework of the DIR concept called PLAY Project. Sixty-eight children participated in the study. Their parents were taught to interact and play with their children and encouraged to independently play and socialize with their children for about 15 hours a week for 8-12 months. Diagnostic assessment was carried out using the FEAS scale and video recording, followed by blinded assessment of the data by a panel of experts. Statistical assessment of score differences revealed significant differences between measures, with 45.5% of the children in the sample making significant progress in social-emotional development [18].
In 2011, the results of a randomized study by Pajareya (Thailand) were published [17]. The study had a similar design to the work of R. Solomon design; it also used data from a control group. The experimental group of children with ASD, in addition to the standard programme of care, received an average of 15 hours per week of interaction based on the DIRFloortime approach, in which the parents themselves participated. The study showed significant improvements in the control group on the FEAS scale, improved emotional development in children according to the FEQ functional-emotional development questionnaire, and reduced autism symptoms according to the CARS Autism Rating Scale [17].
In 2012, a second article by Pajareya [16] was published describing a one-year study of the impact of training parents to interact with children with ASD using the DIRFloortime approach. The study included 34 children with ASD between the ages of 2 and 6 years. Parents of these children were given individual training sessions, lectures and group meetings aimed at teaching interaction within the framework of DIRFloortime techniques. The children's parents played independently with their children for 14 hours per week according to DIRFloortime principles; in addition to this programme, the children received other support options. The results showed that 47% of the children had a 1.5-fold improvement in functional-emotional abilities, significant progress on the FEAS scale, and a significant reduction in autism symptoms on the CARS scale [16]. A weakness of this study design is the lack of a control sample.
In 2014, Solomon R. et al. published an article on the evaluation of the Play and Language for Autistic Youngsters Home Counselling Project (PLAY project). The study involved 128 children with autism or pervasive developmental disorder (DSM-IV diagnostic criteria) aged 32 to 71 months who were divided into experimental and control groups using a randomisation procedure. All 128 children received the standard state support programme, but the parents of the experimental group also received a year of monthly consultations with PLAY project specialists aimed at improving parent-child interaction in accordance with the DIRFloortime principles [19].
To train parents in techniques and methods of play support for their child, PLAY counsellors played with children in the presence of parents for 15-30 minutes. Parents also sent the counsellors a 10-minute video of their interaction with their child. The consultant analysed the video and gave the parents recommendations on how to improve the interaction. Families were encouraged to engage their child in 15-20 minute play sessions throughout the day for a total of about 2 hours per day.
The evaluation was conducted before and after the intervention, looking at such parameters as changes in parent-child interaction, the level of speech and general development of the child, and the severity of autism symptoms. In addition, the level of parental stress, the presence of symptoms of depression and the quality of counsellors' work were assessed.
The results of the study showed significant improvements in the experimental group in the following indicators: parents became more responsive to their children's signals, learnt to adjust to their child's individual characteristics; within the framework of the ADOS assessment, a more than twofold decrease in the manifestation of autism symptoms was observed in the children of the experimental group. Parents' stress levels remained the same and symptoms of depression decreased [17].
A pilot study of a home visiting programme based on the DIRFloortime approach is described in Liao et al. [14] described a pilot study of a home visiting programme based on the DIRFloortime approach. Eleven children with ASD aged 45 to 69 months and their mothers participated in the study. They were assisted by an occupational therapist in the home for 10 weeks to teach the mothers individually for 2 hours once every 2 weeks and to explain to them the basic principles of the DIR approach. As part of the study, mothers were required to play with their children for 10 hours a week, and all the children in the study attended standard support programmes (kindergarten, speech therapy and occupational therapy). It was found that the children had significant positive changes in mean scores on emotional functioning (FEAS scale), communication and daily living skills (VABS scale). Mothers of children with ASD noticed positive changes in their relationships with their children, and their Parental Stress Index scores decreased [14].
In a study by Casenhiser et al. [11] compared two types of care - traditional community-based care and care based on the DIRFloortime approach, the MEHRIT care programme. This study was a randomised and controlled trial, involving 51 children aged 2 years to 4 years 11 months, randomly allocated into two groups: the MEHRIT targeted care group (25 children) and the control group (26 children). Children in the control group received an average of about 3.4 hours of various assistance per week, children in the experimental group received about 2 hours of individual MEHRIT sessions weekly, and parents of the children were also trained in developmental interaction skills with their children. Families in the experimental group were instructed to interact with their children for about 3 hours per day. In addition, parents in the experimental group reported that during treatment, some children received weekly individual sessions (20-30 minutes) for 3 months [11].
All children who participated in the study using diagnostic tools such as the ADOS and ADI parent interview were diagnosed with autism spectrum disorder, with their medical diagnosis corresponding to pervasive developmental disorder. In addition, the control and experimental samples had no significant differences on the Language Scale, the Bayley Cognitive Scale, or the Wechsler Intelligence Scale for Preschoolers.
For each child, a team of professionals including a speech therapist, occupational therapist and clinical social worker created a therapy plan.
The diagnostic session, which was conducted at the beginning and end of the study, included a video recording of 25 minutes of play between a parent and their child. The diagnostic play session consisted of 15 minutes of free play, 5 minutes of tactile play and 5 minutes of motor play. Video recordings were coded and evaluated by a panel of 6 experts. Communicative behavior was also coded. The assessment was carried out using a large set of diagnostic tools.
The results of the mCBRS (A modified version of the Child Behavior Rating Scale (Kim and Mahoney, 2004; Mahoney and Perales, 2003)) showed significant differences between the control and experimental groups on the measures of "engagement", "initiative and joint attention". Children in the experimental group who received the MEHRIT programme significantly outperformed the control group on these measures.
The results of scores on the PSL IV or CASL language scales showed no significant differences in language development between children in the control and experimental groups.
Correlation analysis of the results revealed a correlation between the indicators "involvement", "initiative and joint attention" and the degree of expression of language delay, which may indicate that in non-speaking children the development of such important qualities and abilities as initiative and joint attention, the ability to engage in emotional contact will contribute to progress in speech development. A correlation was also found between the degree of development of parental interaction skills, which are the focus of the training, and positive changes in the interaction skills of children in the experimental group [11].
In 2015, Casenhiser [10] published an article reanalysing the results of Casenhiser's 2013 study [11], in which a different principle of analysing speech development was applied - this was possible due to the availability of diagnostic video recordings of the 2013 study. The authors drew attention to the fact that the language tests used in the initial study assessed primarily such formal properties of speech as vocabulary, syntax, and morphology, whereas the MEHRIT programme focuses primarily on the development of social interaction. The authors concentrated on the study of different speech acts, as well as on indicators such as MLUm (mean length of utterance in morphemes), number of utterances. Re-analysis of the results showed that children of the experimental group significantly improved such indicators as MLUm (mean length of utterance in morphemes), total number of utterances, length of utterances, type of response, number of communicative acts, number of words used in interaction, number of different types of speech functions used during interaction, speed of response to the communicative partner and randomness of responses.
This study is the most rigorous in terms of design, with the distinctive feature that for the majority of children in the experimental group it was the DIR-based intervention - the MEHRIT approach - that was the main intervention and was highly effective compared to other therapies. This study also pointed to the importance of functional language measures in guiding and evaluating the treatment of children with autism [10].
In order to evaluate the effectiveness of the DIRFloortime approach, a systematic review was published by Boshoff K. in 2020, which analyzed 9 studies that showed a positive effect of DIRFloortime therapy, manifested in improved social-emotional development, but the authors of the review wrote about the need for more studies with greater methodological rigor, precision and using more reliable indicators [9].
In 2023, a systematic review by Divya K.Y. was published for the same purpose, in which 12 studies of the DIRFloortime approach were analyzed. Analysis of these studies showed significant progress in children with autism in such indicators as emotional functioning, communication, daily living skills, improved interaction with parents, and absence of side effects [12].
 

Studies of the DIRFloortime Approach Carried out in Russia

 
While there are scientific publications mentioning the DIRFloortime approach, only one non-randomised controlled trial has been performed in Russia to date [6].
N.V. Romanovsky describes a formative study conducted on a sample of 18 children (ages from 3 years to 3 years 11 months) diagnosed with infantile autism (F-84, according to ICD-10). This group of children regularly attended comprehensive classes based on the DIRFloortime approach, lasting from 4 hours and 40 minutes to 6 hours per week at the "CENTRE FOR HEALTH AND DEVELOPMENT NAMED AFTER ST. LUKA".
All classes were conducted in the presence and at the request of the parent with his/her active participation. It is important to note that during this period the children of the experimental group did not attend any other classes.
The control group consisted of 19 children of the same age with the same diagnosis, who did not receive this type of assistance; the children were mainly engaged with a defectologist. Diagnostic measurements were carried out twice with an interval of 4 months (from May to October 2021). The results showed that children in the experimental group showed statistically significant positive dynamics in such areas as communication, everyday living skills, motor development on the VABS scale, as well as desire for emotional contact, communicative initiative, bilateral interaction on the FEAS scale. Similar changes were not observed in the control group [6].
Thus, the DIRFloortime approach has a fairly solid evidence base, but the practice of its application is very variable. For example, some studies investigate the DIR approach as an effective addition to standard programmes of care for children with ASD, but there are also studies that assess the effectiveness of the approach as the main and leading one.
 

Discussion and Conclusion

 
Summarizing the results of the analytical review, we can say that the DIRFloortime model has a good evidence base and can be considered a scientifically sound early intervention practice. The effectiveness of the DIRFloortime model has not been sufficiently researched in the Russian-speaking space, which is an urgent task for research practice in the near future.
The following experimentally proven algorithms can be identified for the DIRFloortime model:
  1. Individualized DIRFloortime sessions should take place at least 2 times a week.
  2. Effective application of the DIRFloortime model involves regular training for parents to interact with their children for between 1 hour per month and 2 hours per week, aimed at:
- explaining basic principles of the DIR approach,
- building game interaction using basic DIRFloortime techniques and strategies,
- ways of building communication and social interaction,
- improving the sensitivity and responsiveness of the parent,
- taking into account the individual characteristics of the child,
- learning how to effectively engage the child in a mutual emotional exchange.
  1. The conditions as well as the methods of training by the parenting specialist should include the use of technologies such as:
- Playful interaction between the specialist and the child (15-30 minutes) in the presence of the parent, followed by an explanation of the parent's actions.
- Joint viewing of video recordings of the parent playing with the child at home (lasting about 5-10 minutes) with feedback from the specialist.
- A written, individualized play plan written by the specialist, including methods, techniques and specific activities for the parent.
  1. Independent playful interaction of parents with their children for about 2-3 hours every day according to DIRFloortime principles.
  2. The existence of an individualized care plan for the child, developed by an interdisciplinary team consisting of an occupational therapist (sensory integration specialist) and at least either a speech therapist, speech pathologist or psychologist.
  3. Interventions should be carried out by an interdisciplinary team of professionals consisting of an occupational therapist and at least one speech therapist, speech pathologist or psychologist.
  4. Regular (at least every 8 weeks) meetings between the specialist team and the family to discuss progress in therapy.
  5. The child receives at least 1 hour of traditional care per week with the DIRFloortime intervention.
  6. Duration of intervention from 1 year or more.
  7. Child's age at the start of the DIRFloortime intervention from 24 months to 59 months.
If all the above algorithms are followed, the following results can be expected from an intervention based on the DIRFloortime model:
  1. Reducing the core symptoms of autism.
  2. Improvement of the child's functional social-emotional abilities
  3. Improvement of speech by such indicators as: number of communicative acts, length of utterances, increase in the total number of utterances, variety of responses, functional use of language.
  4. Improving child-parent interaction.
  5. Reducing symptoms of depression in parents of children with A

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Information About the Authors

Nikolay V. Romanovsky, PhD in Psychology, Research Associate, Faculty of Clinical and Special Psychology, department of neuro – and pathopsychology, Moscow State University of Psychology and Education, Moscow, Russia, ORCID: https://orcid.org/0000-0002-2467-9578, e-mail: romanovskij2@gmail.com

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