DIR FloorTime: The science behind the play
What is it?
DIR (developmental, individual differences and relationship based model) is a framework initially proposed by Child Psychiatrist Dr Stanley Greenspan outlining human social and emotional development, particularly in relation to Autistic children. DIR FloorTime is the practical application of this framework. FloorTime is a transdisciplinary approach, meaning no one health care field ‘owns’ it. Instead it encourages therapists to look at the child as a whole within their community, and adjust intervention to best suit their needs.
At its core, FloorTime is a parent training program, where clinicians empower parents to connect with their children and provide meaningful and functional intervention. Through learning how to follow their child’s lead, parents and Autistic children are empowered to connect, communicate, and develop a range of skills. We take the time to learn about a child’s communication, family, sensory profile, interests and developmental history to support a range of skills from engagement to connecting complex ideas. Through working on the foundational skills of regulation and engagement, therapists and parents are able to build up to those more complex language skills.
Practically, FloorTime looks a lot like child-led play. That’s because it is! For parents and clinicians this can feel confusing, particularly when coming from a framework of adult led interactions. Doubts around efficacy and a focus on getting back to ‘real therapy’ plague many clinicians. Parents may wonder why their child is ‘just playing’ and when the ‘real work’ will begin. Let’s take a look into the science behind this child led approach to uncover what it can achieve for our Autistic children.
What we know
Developmental approaches (such as DIR FloorTime) were shown in a meta-analysis (one of our highest levels of research) to be promising in supporting Autistic children’s social emotional development and communication (Sandbank et al., 2020). These approaches were noted to have more evidence than approaches that used a solely behavioural ideology. Functionally, this means a developmental component using play and naturalistic learning is beneficial for our Autistic clients.
Several systematic reviews into DIR FloorTime specifically have found increased social and emotional development, communication, activities of daily living, and satisfaction in parent - child relationships (Divya et al., 2023; Boshoff et al., 2020)
Smaller studies found Autistic preschool children undergoing DIR FloorTime intervention experienced improved social communication and sensory processing outcomes (Reis et al., 2018). This is particularly of interest as Barmak and Baş (2024) found a significant link between sensory processing difficulties and Developmental Language Disorder (DLD). This means the sensory components of intervention are important for our children experiencing language disorders.
What we don’t know (yet!)
What the ‘core ingredients’ are to weave language intervention into developmental approaches. The evidence was stronger for social and emotional development rather than specific language development (Binns & Oram Cardy, 2019). This makes sense as the DIR framework is not designed as a standalone language intervention.
Long term outcomes for Autistic children’s communication and language development when using the DIR framework over a prolonged period of time.
Large scale outcomes and information. Simply put, we need more research and high quality studies. The evidence base is growing in this area and I am looking forward to seeing more systematic reviews and meta-analyses to help us refine our practices over time.
The bottom line
DIR FloorTime is a research backed approach to supporting parent - child connections, social and emotional development, and play. The hats we wear as clinicians can help guide us into adding additional layers to this framework based on the knowledge we currently have. For speechies, this is our knowledge on speech sound, language, and literacy development. By harnessing the foundation skills and regulation needed to learn, we can achieve excellent outcomes for our Autistic clients across all areas.
I like to explain it to parents and clinicians using imagery: imagine building a house on sand. You might manage to get it to stand but it will collapse in the first storm. The same goes for language development. If we start with the walls and windows (wh questions, recounting, and other higher level skills) and no foundation (regulation, engagement, and praxis) we are setting ourselves up to drop it all the moment we step out of the clinic. To make lasting change that is meaningful and effective, we need to focus on connection rather than compliance. Language has to mean something, otherwise, what’s the point?
References
Barmak, E. and Baş, B. (2024) ‘Investigation of the relationship between sensory processing skills and language development in children with developmental language disorders’, Brain and Behavior, 14(12). doi:10.1002/brb3.70105.
Binns, A.V. and Oram Cardy, J. (2019) ‘Developmental social pragmatic interventions for preschoolers with autism spectrum disorder: A systematic review’, Autism & Developmental Language Impairments, 4. doi:10.1177/2396941518824497.
Boshoff, K. et al. (2020) ‘Child development outcomes of dir/floortime TM-based programs: A systematic review’, Canadian Journal of Occupational Therapy, 87(2), pp. 153–164. doi:10.1177/0008417419899224.
Divya, K. et al. (2023) ‘Dir/Floor time in Engaging Autism: A Systematic Review’, Iranian Journal of Nursing and Midwifery Research, 28(2), pp. 132–138. doi:10.4103/ijnmr.ijnmr_272_21.
Reis, H.I., Pereira, A.P. and Almeida, L.S. (2018) ‘Intervention effects on communication skills and sensory regulation on children with ASD’, Journal of Occupational Therapy, Schools, & Early Intervention, 11(3), pp. 346–359. doi:10.1080/19411243.2018.1455552.
Sandbank, M. et al. (2020) ‘Project AIM: Autism intervention meta-analysis for studies of young children.’, Psychological Bulletin, 146(1), pp. 1–29. doi:10.1037/bul0000215.
