ChildCenter voor autistische kinderen


On the DIR model

by drs Pim Donkersloot

Good evening.

I am very happy to see that so many of you are present here and are interested in learning about the floortime approach to treating children with an autistic spectrum disorder.

My name is Pim Donkersloot. I am a developmental psychologist, author and the father of two autistic children. I have trained with Dr. Stanley Greenspan, Clinical Professor of Psychiatry at the George Washington University Medical School, and author of, among many other works, "The Child with Special Needs". I recently translated this book into Dutch, together with three colleagues. One of them, Karen Dun, a neuropsychologist and occupational therapist who follows Greenspan's approach in her work, is here tonight.

We - that includes my colleague Marius de Vos - are here to talk to you about the DIR-model based on the theories and findings of Dr. Greenspan, and his Floortime approach to reaching and teaching the child with special needs.

Marius is a very talented play-therapist who has a great deal of expertise in the Floortime method. Among many others, Marius has worked intensively with my seven year old daughter Julia for 5 years with excellent results.

We have a limited amount of time to lay out the fundamentals of Greenspan's theories and approaches to optimizing the potential of children with autistic spectrum disorders and other challenges of communicating and relating. Following our introduction and overview there will be ample time for your questions.

(I would now like to ask the following: By a show of hands: Who is here as the parent of a special needs child? Who is here as a professional caregiver? Okay. Who is somewhat familiar with the DIR-model and Floortime? Or has read about it on the internet? Great, because we somewhat expected this, which means that we don't have to rehash the very basics)

To begin with, the DIR-model is the theory behind the floortime-approach. The DIR-model, about which I will later elaborate,, stands for "Developmental Individual differences Relationship-based model," and is a framework for the assessment of and intervention for children with autistic spectrum disorders and other problems of relating and communicating - in short , special needs kids. The DIR model identifies the child's developmental level of emotional and intellectual functioning (the D); determines its individual way of reacting to and comprehending movement, sounds, sights, and other sensations (the I); and formulates learning relationships and interactions (the R) at home, in school, and in different therapies (speech, occupational) geared to the child's profile. Individualized learning relationships utilize the child's natural interests and emotions (by following his/her lead) and create interactions that help him or her master the stages of relating, communicating, and thinking.

We believe that this model is special, because unlike other models that focus on isolated surface behaviors and circumscribed cognitive skills, the DIR-model emphasizes the developmental approach, which synthesizes and integrates all the best information we have about how the mind and brain grow.

I will now describe the DIR model in reverse, starting with the R for relationship-based.

With its focus on affect, emotion and relating, the emotional development of the child is the cornerstone of the DIR-model. According to this view, without fundamental relatedness with significant others, language and cognition - for example - will not development normally. Emotions form the basis of all developmental milestones.

We now know that the growth of the mind and brain in the early years is directly related to a child's interactions with caregivers. Consider: When you think about something with affect (f.e. passion) your memory functions optimally. We all know that. Think, for example about your favorite hobby and your memory is crystal clear.

Regarding the "I" from the DIR model: traditional treatment approaches for special needs children have proven to be inadequate, as these children have unique processing problems. Children differ in the way they process sound (auditory processing and language), the way they process what they see (visual-spatial processing) and the way they plan and sequence actions. For example, we find that many children with autistic spectrum disorders have severe problems with motor planning and sequencing, which underlies much of their repetitive behavior: If you cannot plan in sequence you are bound to repeat. Thus, motor planning is key to understanding many of the atypical symptoms of special needs children.

Connected to this, children differ in the ways in which they modulate sensation. Some kids are over reactive (= oversensitive) to things like sound and touch, so they hold their ears or they avoid and push away when people try to tickle them. On the other hand, when a child is oversensitive - f.e. to sound and touch - it does not necessarily mean that he or she is that by nature. Rather, it indicates an inability to select due to lack of affect, emotional selection or judgement (the typical child will f.e.: "I want/don't want to hear this because I don't like this song").

Other children crave sensory input and need more touch or more noise. And some children crave both: they need more sensory input but they get overloaded because they also have areas of sensitivity. For these kids it is very hard to find the right sensory pattern to pull them in and engage them. We find that many children who are self-absorbed are under-reactive to things like sound and touch. Other children who are very avoidant and keep running away from people - not because they do not love people but because they are over-reactive (hypersensitive) to f.e. sound and touch.

Thus, we need to look at the sensory modulation of the child to find the right pattern to pull that child into a relationship. In short, we need to look at the unique, individual differences in the way children process their sensations and plan their motor actions, because it explains a lot of their surface behaviors. When you work with the underlying processing differences, then you can influence many behaviors and help the child be adaptive, across a broad range of issues, rather than just work on isolated cognitive skills or isolated cognitive behaviors. You help the child to regulate him/herself in new ways.

Regarding the D in the DIR model:

As mentioned before, we have traditionally thought of development in very isolated stages. For motor development we had a timetable for sitting up, for walking, etc. In language development, we identified when the first sounds, the first words were made, etc. In different areas of cognitive (or intellectual) development, we identified the stage at which a child would search in your hand for an object, or could stack blocks in a certain way, and so forth on. In social and emotional development - so often the biggest challenge in children with autistm - we could identify when a child will greet, when a child will play with peers, when a child will engage in pretend play. etc.

But in fact, based on Greenspan's research, all these areas of development are interrelated. Up to now, we haven't had a functional developmental roadmap for the mental team: language, cognition, affect and emotions. Over the last 25 years, Stanley Greenspan and his colleagues have, through observation and research, identified six core levels that occur in the first four years of life that simultaneously promote a child's intellectual and emotional growth. We now understand the core levels that synthesize and integrate all the different capacities on the developmental ladder. It is called the developmental ladder because the child needs to reach the various levels in sequence - one level leads to the next.

(With overheadprojector I will show the six milestones)

In short, the six levels are: Within the first 3 months: The capacity for regulation and shared attention (in other words: the ability to stay calm and observe the world around oneself) Between 3 and 6 months: Engagement with warmth and trust and intimacy (an emotional connection to mommy, daddy and other caregivers) By 9 months: Two way purposeful communication (initiating and responding in a back and forth manner with gestures such as cooing, head nodding, turning to look, etc). Greenspan calls this opening and closing circles of communication. The child is able to take mommy by the hand, walk her to the fridge, bang on the door and point to the juice. By the time the child is a year till a year and a half, ideally the child is able to engage in interactive problem solving/use of gestures in a continuous flow. Also often referred to as joint attention. It is shared social problem solving (taking daddy by the hand, and through multiple back and forth gestures getting him to pick you up so you can reach for the toy on the shelf) (24 - 30 months) Functional use of ideas, or creating ideas. In language, f.e., it would be, "Me hungry, juice please", or in pretend play, feeding the dollies, hugging the dollies. Between 3 and 4 years: the sixth level is the ability to build bridges between ideas; to connect ideas logically (thinking). An example: When the child says "I want to go out" and you say "why?" "Because I want to play"

When it comes to children with challenges, original observers ignored the fact that in many of the families where there are no developmental challenges, the interactive patterns that support these six functional levels occur automatically. They are taken for granted, so to speak. When you have a child with special needs, we all know that for mental growth these children need (our) very specific environmental support to ignite each of these six functional levels.

Recent studies have shown that special needs children fare much better than we ever expected when we apply this model, because we are focused on an integrated understanding of human development. We can help children with f.e. severe language problems to learn to speak so much better if we first get them engaged and get them purposeful in gestures, and then we can build in the symbolic speaking and thinking capacities. If we try to do the speaking and thinking without the foundation, without these early levels I mentioned in the developmental roadmap, it will not go as well and they may end up with a bunch of splinter skills.

Taking this important roadmap into account, which should include specifically spontaneous interaction, brings us to what we call,floortime. The DIR-model is the theory, Floortime is the practice. Ideally, it requires an investment of six to eight 15-20 minute sessions per day, following the child's lead, becoming a player with the child, getting down on the floor and supporting each of these functional developmental capacities. What is important here is maintaining an even flow of interaction between mommy, daddy, or the caregiver, and keeping the child engaged with lots of affect and emotion, helping the child to learn to cue and interact. The process in the play is much more important than the content. In floortime you are trying to build the relationship, build the communication, build the affective range, build the emotional range. It fills in the foundation for children who may have developed higher skills but cannot really use them effectively and functionally to relate to people, to communicate, to play with other kids. By taking into account the unique individual profile of each child, we may use different approaches while remaining animated, engaging, regulating and interactive simultaneously "As Dr. Greenspan would note while observing a floortime session "Now you're cooking! Go for the gleam in the child's eyes!" Four you as a parent or as a professional caregiver, faith in the underlying theory if dr. Greenspan is, in my view, essential/critical in order to generate and sustain that kind of enthusiasm, that kind of passion, that kind of energy, that kind of motivation. That is the reason that I presented this brief introduction of the DIR-model and I hope it will motivate you to explore in greater depth Greenspans model and the floortime approach.

With reference to the basic principles of Floortime as highlighted on the overheadprojector, I am pleased to give the floor, so to speak, to Marius, who will talk about floortime in practice . This will be accompanied by some televised footage.