I went to a workshop on DIR Floor Time. You may be asking what this is and it is called Developmental, Individual-Difference, Relationship-Based Play Therapy Model for children and adolescents with Autism Spectrum Disorders and is also used with selective-mutism. It is a non-directive therapy, much different from cognitive behavioral therapy. It is not quite child centered behavioral therapy. Here, I will be providing an overview of what DIR Floor Time is and its tenants. In Part II, I will follow-up with specific interventions. You need to get the underpinnings of this model in order to be able to apply the interventions. The material gathered for this article was provided by Esther Hess, Ph.D., Director of the Center for the Developing Mind. There are specific trainings available for this model and this post and Part II does not replace the need for training. It just gives you an overview of what it is.
DIR Floor time looks at the developmental level of each child. There are certain milestones children need to reach before they can move on to the next developmental level in terms of developing relationships. For example, by three months the infant should be able to regulate and take interest in the world, by five months they should be able to form relationships (attachments), by nine months there should be intentional two-way communication, by thirteen months there should be a complex sense of self and behavioral organization, by eighteen months there should be a complex sense of self and behavioral elaboration, by twenty-four months there should be emotion idea and representational capacity, and by 30 months there should be emotional ideas and representational eradication.
In the Autistic Spectrum child they do not reach these miles. DIR Floor time starts where the child is. The child may be five, yet developmentally like a two-year old. You work with them at the two-year old level, yet recognizing their age and knowing that intellectually they may be their stipulated age, not necessarily delay. The model encourages a multi-model approach and encourages evaluations and working along with not only the family, but with the speech and language pathologist, occupational therapist, physical therapist, and educator. Assessment is based on the findings of these disciplines. There is emphasis to check family members, family patterns, and family needs. The family will be an part of treatment and they have to be willing to take part in sessions and practice the ways shown to them 5-6 times a day. It is a big commitment. Siblings can be helpful too. You will also be making observations in the home.
You will be working on functional development capabilities beginning at the bottom rung, which includes focus and attention and working your way up to engaging and relating, to simple two-way gesturing, to complex problem-solving, to creative use of ideas and symbols, and finally to analytic / logical thinking.
There will also be things you need to consider for you as the clinician. Do you use a calm voice? Do you give gentle looks? Is your body posture supportive? Are your actions non-intrusive? Do you use encouraging gestures? Are you aware of the child's rhythms? Are you comfortable following the child's lead? Are you aware of the child's feelings? Are you talking into account DIR? Did you observe long enough? Are you using affective cues through gestures to stay connected? Are you asking too many questions? Did you pursue?
The primary challenges to an interaction on the part of the therapist are level of comfort with the child's themes and feelings. Do you deepen or deflect? The challenges on the part of the child are avoidance, disengagement, poor communication, poor motor-planning, passivity, low tone, hyperactivity, poor symbolism, fragmentation, and anxiety. The challenges on the part of the parent are taking over the lead, changes the topics, controls the child's body, over-relationships on sensory motor activities, misses cues, lacks affect, poor timing, concrete, works below level, works above the child's level, is angry, and / or is depressed.
Autism is a multi-system developmental disorder. There are three types:
Pattern A-Mostly aimless and unrelated, severe motor planning difficulties, severe auditory planning difficulties, severe auditory processing, affect flat, unmodulated or inappropriate, self-stimulation and rhythmic behaviors, poor muscle tone and under-reactive, over-reactive to sound and touch, and overly active and extremely distractible.
Pattern B-Intermittently related, simple intentional gestures fleeting, affect accessible but fleeting, enjoys repetitive or perseverative activity with objects, very rigid and reactive to change, has mixed patterns of sensory reactivity and muscle tone, poor motor planning.
Pattern C-More consistent relatedness and reactivity even when avoidant and rigid, islands of warm pleasurable effect, use of simple social gestures, use of intermittent complex gestures, resists change and perseverative, but allows other to join in, mixed pattern of sensory reactivity and motor planning, tenders to over-react, auditory less severe, use some words in scripted or rote form.
This gives you an overview of the theory behind DIR Floor Time. In Part 2, we will look at interventions so we can have good dates with our autism spectrum disordered clients. You need to be aware that there are specific trainings that teach this method. I am just giving you an overview and this should not be considered replacement for the training.