Review of Randomized Control Trial of DIR/Floortime Therapy: “Learning through interaction in children with autism: Preliminary data from a social-communication-based intervention”
Written by Sara Gershfeld, MA, BCBA and Tristram Smith, PhD
Parents and clinicians frequently face the issue of making informed decisions amongst heated debates over the most effective approaches for treating young children with autism (Prizant & Wetherby, 1998). Of the current approaches used to treat autism, there lies a continuum ranging from intensive discrete-trial-training, to behavior analytic treatment that combines many different instructional methods, to social-pragmatic and developmental approaches. This article provides a basic description of a class of interventions that have recently received increased attention – Developmental Social Pragmatic (DSP) interventions.
Casenhiser, Shanker and Stieben (2011) evaluate DSP as a method of improving social interaction skills of children with autism spectrum disorder (ASD) and state that these different approaches may teach the same types of behavior, but approach them differently than a traditional behavioral approach.
For example, most interventions acknowledge that eye contact is related to increased joint attention and language (Casenhiser, 2011). As such, interventions aim to teach children with autism to make eye contact. A DSP perspective might suggest that exhibiting eye contact is not what is important, but rather that it is imperative to share the eye contact in a social or play experience. Thus, Casenhiser (2011) reasons that a DSP model focuses on the function of the behavior to engage socially with a peer or adult, whereas a behavioral approach might look at the topography of the behavior as important independent of whether it occurs in a social experience or not (for example, attending to instruction). This basic assumption forms a divide between the DSP perspective and a behavioral perspective.
Over the course of development of DSP approaches, treatment options such as the Hanen Method (Manolson, 1992), Relationship Development Intervention (RDI; Gutstein, 2001), and Developmental Individualized Relationship-based (DIR) Intervention (Greenspan & Wieder, 2006) have received attention from parents of individuals with autism despite a lack of research that uses the “gold standard” of research methodology – a randomized controlled trial.
In this study, Casenhiser and colleagues (2011) examine a DSP approach known as a developmental, individual-difference, relationship-based (DIR®) model, which is often interchangeably referred to as Floor-time Therapy. The DIR®/Floortime approach focuses on helping individuals with ASD master skills related to communication, thinking through understanding of developmental milestones, respecting a child’s individual differences and challenges, and asserting the importance of building relationships with primary caregivers to encourage development. Although the theory behind this type of approach is well explored using anecdotal evidence in Greenspan and Weider’s book “Engaging Autism,” there is a lack of robust evidence to validate its effectiveness experimentally (Greenspan & Weider, 2006). As such, Casenhiser and colleagues evaluate the DIR®/Floortime approach as an intervention aimed at improving the socio-communication skills of individuals with autism using a randomized control trial.
This study enlisted 51 children ranging from 2 to 5 years old. Though this highlights the relatively large sample size, it is unclear how many children did not qualify for this study, did not enroll, or dropped out. Casenhiser and colleagues also mentioned that recruitment occurred with parents that were interested in receiving a DIR-based intervention. It is not articulated whether parents who were eligible but did not have a specific interest in DIR therapy were not included in this sample.
Numerous exclusionary criteria were applied that are not atypical for these types of comparison studies (Dawson et al., 2009). Twenty-five participants were assigned to a tar-get group that received 2 hours of DIR®-based therapy per week and parent coaching at the Milton & Ethel Harris Research Initiative (MEHRIT). Twenty-six participants were assigned to a community group that received an average of 3.9 hours/week of a variety of different services ranging from an unspecified combination of speech therapy, applied behavior analysis (ABA), occupational therapy, social skills, day care, and/or other alternative treatments including diets and hyperbaric oxygen therapy.
Although the community group represents a diverse spectrum of treatments that a typical individual with autism might receive, neither treatment groups received intervention at the suggested intensity documented through experimental literature to show progress in a number of developmental domains. Additionally, the intervention received by the com-munity group was well below the hourly level of researched low-intensity interventions (Eldevik, Eikeseth, Jahr,& Smith, 2006), despite numerous past research studies indicating that intensive behavioral intervention is more effective than eclectic therapy (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005). Lastly, the authors did not indicate whether the community group participants received this eclectic combination of services from the same providers or if there were any standard methods documenting whether staff had the proper training necessary to administer the therapy used in the community group. For example, for an individual receiving ABA, training and supervision should assure competencies in a number of areas including experience designing and implementing comprehensive ABA programming for individuals with autism, which should involve areas ranging from “learning to learn” (e.g. listening, imitating, following directions), social interaction, self-care, school-readiness, communication, to play and leisure (Celiberti, Buchanan, Bleecker, Kreiss, & Rosenfeld, 2004). If these and other competency-based measures are not met, it is expected that an individual with autism receiving this type of service at any intensity or duration will likely make minimal (or at least less than optimal) progress. Thus, concerns can be raised regarding the control group chosen in this trial.
Treatment implementation for the target group occurred by licensed speech-language pathologists or occupational therapists. These staff members were trained for 3 weeks on a number of DIR® techniques. The authors do not address a basic question regarding external validity: Is the training received by these staff members aligned with the training level of typically trained DIR/Floortime therapists? The authors mention that there is a certification offered through Serena Weider, but many DIR/Floortime therapists do therapy without this certification. Even with a certification, there lacks a manual or guide used to standardize the intervention techniques. There is no measure of whether the providers implemented the intervention as intended by the developers of the intervention. Thus, it is difficult to say what occurred in the intervention session or how it could be replicated. As such, results of the study may not reflect those that would be observed if an individual with autism received this treatment in a natural setting.
Results & Data Analysis
Results indicated that there were no significant differences observed on all scales prior to treatment. Ratings were coded by trained staff blind to the treatment condition. After treatment, the researchers examined the relationship between participant group placement and 5 scale items (attention to activity, involvement, compliance, initiation of joint attention and enjoyment in interaction). Improvement was significantly greater on these items than those made by the community group, except in the domain of compliance. In all measures, the community treatment group did worse at the end of 12 months except in the category of independent thinking.
Speech-language pathologist staff, blind to the participant condition, conducted pre- and post-assessments and found no significant difference on two standardized language scales (PLS-4, Zimmerman, Steiner, & Pond, 2006; CASL, Carrow-Woolfolk, 1999). A modified standardized measure had predictors of language change (mCBRS, Kim & Mahoney, 2004), but the authors noted that it was difficult to ensure validity since this scale had been modified following scale standardization. Caregiver behavior was also investigated and statistical differences showed that the MEHRIT group showed improvement on all items except a Sensory-Motor Support item. No significant associations for compliance were indicated in this scale either.
Though these results indicate some improvement based on the intervention, statistical significance only indicates that the differences between groups (however small) are not likely due to chance factors, but does not indicate that these differences are meaningful. It is also unclear how the group averages apply to individual children within the groups (for example, how many children within each group made significant gains or to what extent outcomes varied from child to child). In addition, because the intervention contained multiple components, it is uncertain how each component influenced the behavior of the parent and child.
By standards of experimental autism literature, this experiment has notable strengths. Casenhiser and colleagues enrolled a relatively large sample size. The randomized control trial used a randomized design consisting of two groups – a treatment (“target”) group and a control group. Participants were randomly as-signed to either group. Participants were paired based on age and baseline language level. This sampling procedure ensured that both treatment groups were similar before intervention. Well-established outcome measures were used to identify participant progress, and included an assessment of whether parents acquired new skills. The experiment also monitored the treatments obtained outside of the study.
Aside from these strengths, this study leaves considerable question regarding the validity of the treatment group improvement when compared with a poorly conceptualized control condition. This control condition was not a “no-treatment” control group, but instead was an undefined blend of procedures with no evidence of procedural integrity, at a level considered less than adequate in the research literature. A better comparison might have contrasted the MEHRIT treatment group with a no-treatment group; an eclectic group at the correct duration or dosage; or a group receiving a behavior-based treatment with high procedural integrity. In addition, results were significant on a modified scale, potentially lacking validity.
A significant area of treatment administration that did not show significant results was in the domain of compliance. Compliance is an important skill for individuals with autism, and many demonstrate opposition when required to complete basic tasks (Ducharme & Drain, 2004). The necessity of learning-to-learn skills such as compliance, attending, orienting, choice-making and simple imitation must be taught early in the intervention process before more complex skills, such as social communication and play, can be addressed (Luiselli, Russo, Christian, & Wilczynski, 2008). It is standard to ensure that a foundation for these skills is present before ad-dressing some of the variables that were explored in this study.
Treating an individual with autism often encompasses biological, developmental and/or behavioral approaches to autism treatment. These approaches all aim to remediate the most pertinent symptoms of an individual with autism. Among behavioral and developmental approaches, there are misconceptions about the difference between these two approaches and the utility of both. Casenhiser (2011) attempts to validate Developmental Social Pragmatic (DSP) Interventions, specifically DIR®/Floortime (Prizant & Wetherby, 1998). Although this study provides an indication of the effectiveness of this approach, it should be independently replicated be-fore it is considered empirically valid. DIR® is an emerging treatment, however families are urged to continue with treatments that are currently empirically supported.
Arnold, A., Randye, B.I., & Claire, C. M. (2000). Eye contact in children’s social interactions: What is normal behaviour? Journal of Intellectual and Developmental Disability, 25(3), 207–217.
Casenhiser, D.M., Shanker, S.G., & Stieben, J. (2011).Learning through interaction in children with autism: Preliminary data from a social-communication-based intervention. Autism, 0 (0), 1-22.
Carrow-Woolfolk, E. (1999). Comprehensive Assessment of Spoken Language. Circle Pines: MN: American Guidance Service.
Celiberti, D., Buchanan, S., Bleecker, F., Kreiss, D., & Rosenfeld, D. (2004). The road less traveled: Charting a clear course for Autism Treatment.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., &Varley, J. (2009). Randomized, con-trolled trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics, 125(1), 17-23.
Ducharme, J.M., & Drain, T.L. (2004). Errorless academic compliance training: improving generalized cooperation with parental requests in children with autism. Journal of American Academy of Child Adolescent Psychiatry, 43(2), 163-171.
Eldevik, S., Eikeseth, S., Jahr, E., & Smith, T. (2006). Effects of low-intensity behavioral treatment for children with autism and mental retardation. Journal of Autism and Developmental Disorders, 36, 211-224.
Green, G. (1996). Early behavioral intervention for autism: What does research tell us? In Behavioral intervention for young children with autism: A manual for parents and professionals (pp. 29–44). Austin, TX: Pro-Ed, Inc.
Greenspan, S.I., & Wieder, S. (2006). Engaging autism: Using the floortime approach to help children relate, communicate, and think. Cambridge: MA: Da Capo Press.
Gutstein S.E., Burgess, A.F., & Montfort, K. (2007). Evaluation of the relationship development intervention program. Autism: The International Journal of Research and Practice, 11(5), 397–411.
Gutstein, S. (2001). Solving the Relationship Puzzle. Arlington, TX: Future Horizons.
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Research in Developmental Disabilities, 26, 359–383.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L.B. (2008). Language outcome in autism: Randomized comparison of joint attention and play interventions. Journal of Consulting and Clinical Psychology, 76(1): 125–137.
Kim, J.M., & Mahoney, G. (2004). The effects of mother’s style of interaction on children’s engagement: Implications for using responsive interventions with parents. Topics for Early Childhood Special Education, 24(1), 31.
Luiselli, J.K., Russo, D.C., Christian, W.P., & Wilczynski, S.M. (2008). Effective practices for children with autism: Educational and behavior support interventions that work. New York, NY: Oxford University Press.
Manolson, A. (1992). It takes two to talk. Toronto: Hanen Centre.
Prizant, B.M., & Wetherby, A.M. (1998). Understanding the continuum of discrete-trial traditional behavioral to social-pragmatic developmental approaches to communication enhancement for young children with autism/PDD. Seminars in Speech and Language, 19,329–353.
Smith, T., & Lovaas, O. I. (1998). Intensive and early behavioral intervention with autism: The UCLA Young Autism Project. Infants and Young Children, 10(3), 67–78.
Zimmerman, I.L, Steiner, V.G., & Pond, R.E. (2006). Preschool Language Scale-4. New York: The Psychological Corporation and Harcourt Brace Jovanovich.