DIR/Floortime (PDF)

Vanessa Slivken, MA, LMFT DIR/FLOORTIME St. David’s Center DIR/FLOORTIME OVERVIEW

The Greenspan Floortime Approach The Interdisciplinary Council on Development and Learning Profectum D = Developmental Functional Developmental Capacities (the trunk) (9 Milestones)

I = Individual Differences (the roots)

R = Relationship-based

These 3 things make up the Developmental Profile of the child

Sensory Emotional Interactions & Motor family patterns Auditory Visual “D” DEVELOPMENTAL

The 9 Functional Emotional Developmental Milestones  Milestone 1: Shared Attention  Milestone 2: Engagement  Milestone 3: Intentionality/Two-Way Communication (5-10 circles)  Milestone 4: Social Problem-Solving & Continuous Flow  Milestone 5: Meaningful Symbolic Communication  Milestone 6: Logical Thinking & Communication  Milestone 7: Multi-causal, Comparative Thinking  Milestone 8: Grey Area Thinking  Milestone 9: Reflective Thinking Off an Internal Standard “I” INDIVIDUAL DIFFERENCES

Sensory Modulation & Processing Auditory/Language Processing  Over- and under- reactive sensory systems  Expressive and receptive  Vestibular and proprioceptive systems Visual-Spatial Processing Emotional Modulation/Regulation  Tracking and scanning  Visual thinking Motor Planning & Sequencing  Gross and fine motor  Balance and coordination “R” RELATIONSHIP-BASED

Relationships include: How to establish a positive relationship:  Caregiver/child interactions  Have fun!  Family patterns  Use AFFECT!  Teacher/child interactions  Show interest and enthusiasm in child’s interests  Therapist/child interactions  Listen – don’t judge or lecture  Sympathize All must reflect on self:  Empathize  What type of individual am I?  How do I react to different emotions?  Does child act differently around me? D R

I FUNDAMENTALS: FOLLOW THE LEAD

Join the child’s interest and activity. Say something and do something! Treat the child’s every action (even repetitive motions) as purposeful and effective. Use your voice, facial expressions, and actions to become the most interesting object in the room.

"There should not be a lull in the emotional environment, fill it with language and affect." FUNDAMENTALS: CHALLENGE

Encourage interaction, communication, and thinking, building complexity with each challenge. Expect a response. Do not try for one desired answer. Let the child think of solutions, move their body, and use their own ideas as much as possible. 2 main approaches:  Playing Dumb & Playful Obstruction

"It's fine to solve the challenge for him, if you think you're losing him. The goal is the interaction, the goal is the activity, the goal is the experience, NOT that one challenge." FUNDAMENTALS: EXPAND

Always increase the interaction by only one new step to encourage a response and not frustrate the child. Let the child expand the interaction and activity when possible. Be patient and avoid filling in gaps or suggesting new directions.

“Pose the problem without solving it for him. If your character falls down, fall down and say you’re hurt. Don’t say “come help me” or “save me”; that’s the solution if you think about it. And even further, once he decides to do that, how are you going to do it. He’s got to keep expanding with his ideas and how to solve those problems. You present the problem as something contextual and that he is interested in; and then he gets to come up with the solution.” RESEARCH/EVIDENCE

• Randomized-controlled studies have identified statistically significant improvement in children with ASD who used Floortime. These studies showed the effectiveness of addressing the caregiver and specific skill improvement including turn taking, two way communication, understanding cause and effect, and emotional thinking. • A pre/post-randomized-controlled trial utilizing an approach based on DIR was published and showed not only statistically significant improvement in specific skill development, but also that caregivers reported a decrease in stress with treatment while the control group showed an increase in stress. • The DIR/Floortime intervention can be effectively replicated in different cultural settings. • Children made significant improvements in two-way purposeful communication, forming relationships, behavioral organization, and problem solving following a home-based DIR/Floortime intervention program. The adaptive functioning of children with ASD improved, especially communication and daily living skills. Mothers of children with ASD perceived positive changes in their parent–child interactions after implementing the home-based DIR/Floortime intervention program. TARGET AUDIENCE

DIR/Floortime targets children on the Autism Spectrum, with developmental delays, who need to overcome challenges resulting from genetic disorders (Fragile X, Down’s Syndrome, etc.), learning delays, and/or physical impairments (i.e. Cerebral Palsy).

The fundamentals of DIR/Floortime don’t depend on chronological age, but rather, functional, emotional, and developmental levels. It is most often used with children, but can and has been used with adults. SETTINGS

DIR/Floortime can be provided at home or in-clinic.  It could be provided in school or in the community; although these environments may make it more difficult to follow the child’s lead. THE GREENSPAN FLOORTIME CERTIFICATION Certification process looks similar across all three organizations with slight variations:  Greenspan: https://stanleygreenspan.com/certification  Level 1: Provisional license to provide Greenspan Floortime services for 1 year  Level 2: Non-provisional practitioner  Level 3: Train parents and practitioners  Level 4: Ability to teach  Qualifications:  18 years or over  Proficient in English (Reading, Listening, and Speaking)  Have worked in child development for at least two years. Acceptable experience includes working at a school, clinic, or hospital with children with developmental challenges. (Self-employed individuals can only apply if they are a licensed professional)  Seems to align well with EIDBI provider qualifications ICDL CERTIFICATION  ICDL: http://www.icdl.com/education/dirfloortime/curriculum  DIR 101: Intro  DIR 201: Basic  DIR 202: Advanced  DIR 203: Coach others  DIR 204A: Become a Trainer and Expert  DIR 210 & 220: Group & Individual Mentoring PROFECTUM CERTIFICATION  Profectum: https://profectum.org/training-programs/certificate-programs/  Introductory Program for Parents & Professionals  Profectum Academy Parent Course  Profectum Academy Administrator/Educator Certificate (beneficial for group or school settings)  Profectum Academy Professional Certificate  Profectum Academy Fellow Certificate (write a comprehensive, long-term case study)  Profectum Academy Trainer Certificate  Profectum Academy Faculty Certificate PROVIDERS

Number of DIR/Floortime Providers in Minnesota:  Approximately 26  Data based on ICDL Directory, St. David’s Center providers certified to provide Greenspan Floortime, and a Google search which resulted in a list from Autism Speaks FAMILY AND CAREGIVER TRAINING

Includes specific training and coaching for parents and caregivers  Parents/caregivers can receive a manual, take the online professional course, and participate in other trainings offered  Sessions include parents/caregivers learning FEDLs and Fundamentals, clinicians modeling these concepts, clinician and parent/caregiver implementing together with child, parent/caregiver implementing with child with clinician coaching, and parent/caregiver implementing and “reporting back” to clinician successes and struggles  6-10, 20-30 minute Floortime sessions every day are optimal; parents/caregivers and clinicians are encouraged to work together to reach this goal.  There are many free resources for families on each of the three DIR/Floortime websites! REFERENCES

Binns, A., Casenhiser, D. M., McGill, F., Morderer, O., & Shanker, S.G. (2015).Measuring and supporting language function for children with autism: evidence from a randomized control trial of a social-interaction-based therapy. Journal of Autism and Developmental Disorders, 2015 Mar; 45(3):846-57.

Casenhiser, D. M., Shanker, S., & Stieben, J. (2011). Learning through interaction in children with autism: Preliminary data from a social-communication-based intervention. Autism, 1-22. http://dx.doi.org/10.1177/1362361311422052

Chen, S., Chen, Y., Hwang, Y., Lee, P., Liao, S., & Lin, L. (2014).Home -based DIR/Floortime Intervention Program for preschool children with autism spectrum disorders: Preliminary findings. Physical and Occupational Therapy in Pediatrics, November, 34(4), pp. 356-367.

Dionne, M., & Martini, R. (2011). Floor Time Play with a child with autism: A single-subject study. Canadian Journal of Occupational Therapy, 78, 196-203. http://dx.doi.org/10.2182/cjot.2011.78.3.8

Greenspan, S. I., Brazelton, T. B., Cordero, J., Solomon, R., Bauman, M. L., Robinson, R., ... Breinbauer, C. (2008). Guidelines for early identification, screening, and clinical management of children with autism spectrum disorders. Pediatrics, 121(4), 828- 830. http://dx.doi.org/ 10.1542/peds.2007-3833

Greenspan, S., & Wieder, S. (1997). Developmental patterns and outcomes in infants and children with disorders in relating and communicating: A chart review of 200 cases of children with autistic spectrum diagnoses. Journal of Developmental and Learning Disorders, 1, 87-141. Retrieved from http://www.playworks.cc/articles/200casechartreview.pdf REFERENCES

Hess, E. (2013). DIR®/Floortime™: Evidence based practice towards the treatment of autism and sensory processing disorder in children and adolescents. International Journal of Child Health and Human Development, 6(3). Retrieved from http://www.centerforthedevelopingmind.com/sites/default/files/IJCHD-2013-6-Hess-Floortime.pdf Lal, R., & Chhabria, R. (2013). Early intervention of autism: A case for Floor Time approach. Recent Advances in Autism Spectrum Disorders, I. http://dx.doi.org/10.5772/54378 Nikolopoulos, C., Keuster, D., Sheehan, M., Dhanya, S., Herring, W., Becker, A., & Bogart, L. (2010). Socially Assistive Robots and Autism. Solid State Phenomena, 166-167, 315-320. http://dx.doi.org/10.4028/www.scientific.net/SSP.166-167.315 Pajareya, K., & Kopmaneejumruslers, K. (2011). A pilot randomized controlled trial of DIR/Floortime™ parent training intervention for pre-school children with autistic spectrum disorders. Autism, 15(2), 1-15. http://dx.doi.org/10.1177/1362361310386502 Pajareya, K., & Nopmaneejumruslers, K. (2012). A one-year prospective follow-up study of a DIR/Floortime™ parent training intervention for pre-school children with Autistic Spectrum Disorders. Journal of the Medical Association of Thailand, 95(9), 1184-1193. Retrieved from http://www.floortimethailand.com/images/info/interesting%20ari/2063.pdf REFERENCES

Salt, J., Shemilt, J., Sellars, V., Boyd, S., Coulson, T., & McCool, S. (2002). The Scottish Centre for Autism preschool treatment programme II: The results of a controlled treatment outcome study. Autism, 6(1), 33-46. http://dx.doi.org/10.1177/1362361302006001004 of a subgroup of children with autism spectrum disorders (ASD) who received a comprehensive developmental, individual-difference, relationship-based (DIR) approach. The Journal of Developmental and Learning Disorders, 9, 39-60. Retrieved from http://playworks.cc/articles/DIRstudy--10yearfollowup.pdf Solomon, R., Necheles, J., Ferch, C., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The PLAY Project Home Consultation program. Autism, 11(3), 205-224. http://dx.doi.org/10.1177/1362361307076842 Solomon, R., Van Egeren, L., Mahoney, G., Quon Huber, M., Zimmerman, P. (2014). PLAY Project Home Consultation Intervention Program for Young Children With Autism Spectrum Disorders: A Randomized Controlled Trial. Journal of Developmental and Behavioral Pediatrics, 35(8), 475-485. http://www.playproject.org/assets/PLAY_Project_Home_Consultation_Intervention.1.pdf Weeks, K. (2009). Musical gold: The partner’s singing voice in DIR®/Floortime™. Growing and Maturing, 15, 22- 23. Retrieved from www.imagine.musictherapy.biz/Imagine/archive_files/Early%20Childhood%20Newsletter%202009.pdf#page=22 Wieder, S., & Greenspan, S. I. (2005). Can children with autism master the core deficits and become empathetic, creative and reflective? A ten to fifteen year follow-up of a subgroup of children with autism spectrum disorders (ASD) who received a comprehensive developmental, individual-difference, relationship-based (DIR) approach. The Journal of Developmental and Learning Disorders, 9, 39-60. Retrieved from http://playworks.cc/articles/DIRstudy--10yearfollowup.pdf RESOURCES https://stanleygreenspan.com/ http://www.icdl.com/home https://profectum.org/ A Partial List of Works by Stanley I. Greenspan (handout) The Greenspan Floortime Approach FAQ (handout) QUESTIONS?

Thank you!

Vanessa Slivken, MA, LMFT Senior Director of Autism Services St. David’s Center [email protected] 952-548-8789