**7. Method**

ing the activity in gestures and words. The adult also uses appropriate facial expression and tone of voice to convey own enjoyment in what the child is doing. Such measures

**3.** Child's Lead: During a floor time session, the child is the director or leader of activities. The adult's role is to follow the child. The aim here is to support the child's activities and initiatives, and through this to take him to a higher level of emotional functioning.

**4.** Expand Ideas: As the sessions progress, the adult builds on the child's play initiatives. Now the adult associates daily experiences with the experiences during the play activi‐ ties. For example, the adult may say "give teddy a bath, like mommy gives you". This planned expansion and addition to child's activities help in development of emotional

**5.** Close Circle of Communication: Once the adult engages the child at a level the child currently enjoys, enters the child's activities, and follows the child's lead, he or she now attempts to move the child from a mutually shared engagement toward more increas‐ ingly complex interactions, a process known as "opening and closing circles of commu‐ nication." In a circle of communication, the adult opens the circle by approaching the child, and the child closes the circle by giving a reaction to the adult's comments and gestures. During session many circles may open and close in quick successions as the

adult interacts with the child. The process leads to two-way communication.

The Floor time approach examines the functional developmental capacities of children in the context of their unique biological profile and their family relationships and interactive pat‐ terns. A longitudinal study [15] was conducted to determine if children with ASD could overcome the core deficits in social behavior and become empathetic and reflective with floor time intervention. A follow-up study of 16 children diagnosed with (ASD) revealed that with the DIR/Floor time approach, a subgroup of children with ASD can become empa‐ thetic, creative, and reflective, with healthy peer relationships and solid academic skills. This suggests that some children with ASD can master the core deficits and reach levels of devel‐ opment formerly thought unattainable with a family-oriented approach that focuses on the

In another study undertaken by Greenspan and Weider [15] where the progress of 200 chil‐ dren who had earlier received Floor time sessions, was reviewed showed that majority of the children learned to relate and engage with warmth, trust and intimacy; they were able to interact, read and respond to social signals; a subgroup of children developed the capacity for imaginative play, creative use of language and reflective thinking. This sub group was included in mainstream schools where the children developed meaningful relationships

enable the adult to open the circle of communication with the child

ideas.

with peers.

**6. Research support for floor time**

700 Recent Advances in Autism Spectrum Disorders - Volume I

building blocks of relating, communicating, and thinking [16].

The study was experimental in nature and employed a pre-test post-test control group ex‐ perimental design. It was conducted on children with ASD residing in Mumbai, India. The objectives were to determine the efficacy of floor time approach for developing social behav‐ ior in pre-school children with ASD, and to compare the levels of social skill achievement by children who received floor time intervention with those who did not.

#### **7.1. Subjects**

Children with ASD within the age group of 3 to 6 years were randomly selected from five pre-schools and intervention clinics located across the city and suburban areas of Mumbai. A total of 26 children participated in the experiment. After selection the children were ran‐ domly assigned to treatment and control groups so that both groups had 13 children each.

#### **7.2. Instruments**

The Behavioral Scale for Social Skills (BSFS) and Floor time intervention were the primary instruments used in the study. They were developed for the purpose of the research. A brief description of both is given below.

tant skill for problem solving that enhances complex communication), and Emotional thinking. Various activities were developed for the purpose of enhancing the target skills.

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**a.** Turn taking: Here the activities selected were done with the authors and then done with peers. Such activities as building block tower, bead stringing, rolling a ball, and throw‐

**b.** Two-way communication: Training a child to respond to his name, reach out to a play‐ thing, and respond to non-verbal communication such as gestures, facial expressions

**c.** Cause and effect: A series of simple activities were done to explain the relationship be‐ tween an outcome and its cause. Tapping a spoon on a surface, shaking a bell, pressing a toy to produce sound or movement, squeezing a wet sponge, opening a transparent box to obtain a desirable object within, etc. were undertaken to help the children estab‐

**d.** Emotional thinking: Pretend play was primarily used for this purpose. Hence, pretend play such as talking on telephone, dressing or feeding the doll (where the authors would at times play out the doll's emotions in the right tone of voice), and playing a shopkeeper etc. were included. The focus was on recognition of emotions. Thus, flash cards of happy and sad faces were used too during the pretend play so that the child was able to understand what did it mean when the 'doll' was 'crying' or the the shop‐

The intervention started after assessing the children's baseline behavior on BSFS. The 26 children were then randomly assigned to experimental and control groups so that both groups had 13 children each. As per the recommended floor time protocol, the researchers observed each child in the experimental group to determine his or her current emotional level, before the commencement of intervention. Each child in the experimental group re‐ ceived 20 sessions of floor time intervention. Each session was of 30 minutes duration. Each session included at least one activity relevant to the pre selected social skills. The sessions started by getting the child's attention by showing a desired object. The researchers used word and simple phrases to describe each activity. The activities were done as given below,

**•** Building a block tower began by demonstrating how to make a tower from the four blocks provided on the floor. The child was then asked to lay a block over the one put by the adult. Subsequently, the adult would put another block over it. The adult would then prompt the child to take his or her turn to put a block on top. The activity was repeated with a peer. Now the peer would take the adult's role. The adult would call out each child's name and say ' your turn now ', as they put one block over the other to make a

ing ball in a bucket were used for teaching turn taking skills to children.

etc was undertaken to develop the ability for two way communication.

Some of the activities are mentioned below.

lish the connection between a cause and its effect.

and parents were encouraged to observe the sessions.

keeper was 'happy'.

**7.3. Procedure**

block tower.


The BSFS had a total of 20 items. Each item was measured on a 4-point scale based on the category of response, namely, correct response; response with verbal prompt; response with gestural prompt; and response with physical prompt. Whereas correct responses were scor‐ ed as 4, responses with physical prompts were scored as 1. The selection of items under each sub head of BSFS was done after detailed discussions with developmental psychologists, pre-school teachers, and many parents. In addition, several observations of pre-school chil‐ dren with and without ASD were also made for selection of items. The instrument was pilot tested on children with ASD belonging to the same age group as the subjects.

**•** Floor time Intervention: Floor time is a comprehensive program for infants, young chil‐ dren, and families with a variety of developmental challenges including ASD. The pro‐ gram aims at enhancing the functional emotional developmental levels and creating those learning relationships that will help the child move ahead in social skills acquisition. Floor time can be tailored to suit the individual needs of children with ASD. Floor time approach was used for treatment in the study. As stated earlier, Floor time approach helps an infant/young child reach the 6 milestones crucial for development of social be‐ havior, namely, self regulation; intimacy; two way communication; complex communica‐ tion; emotional ideas,; and emotional thinking. However, in this study, the treatment was directed toward achievement of 4 milestones – Turn taking (a component skill in intima‐ cy), Two way communication, Understanding of cause and effect relationship (an impor‐ tant skill for problem solving that enhances complex communication), and Emotional thinking. Various activities were developed for the purpose of enhancing the target skills. Some of the activities are mentioned below.


#### **7.3. Procedure**

**7.2. Instruments**

description of both is given below.

702 Recent Advances in Autism Spectrum Disorders - Volume I

and with peers.

and then with words.

The Behavioral Scale for Social Skills (BSFS) and Floor time intervention were the primary instruments used in the study. They were developed for the purpose of the research. A brief

**•** Behavioural Scale for Social Skills: The BSFS was used as a measure at both pre and post

**a.** Turn taking: This is one of the bases for development of social skills and inferring oth‐ ers' intentions correctly [20]. Turn taking includes use of play material with an adult

**b.** Two-way communication: As a child enjoys intimacy in a safe and calm manner, he re‐ alizes he can have an impact on others. The child expresses a feeling or intention, and his partner responds. This is the beginning of communication. Two-way communica‐ tion enables the child to enjoy intimacy and initiate interaction through gestures at first

**c.** Understanding of cause and effect: This is a basis for development of thinking skills. The ability to see the relationship between an event and the factors leading to it helps a child decode the world around him. Understanding of cause and effect relationship im‐

**d.** Emotional thinking: According to Greenspan, emotional thinking is the ability to build bridges between ideas to make them reality-based and logical. Ideas are linked together

The BSFS had a total of 20 items. Each item was measured on a 4-point scale based on the category of response, namely, correct response; response with verbal prompt; response with gestural prompt; and response with physical prompt. Whereas correct responses were scor‐ ed as 4, responses with physical prompts were scored as 1. The selection of items under each sub head of BSFS was done after detailed discussions with developmental psychologists, pre-school teachers, and many parents. In addition, several observations of pre-school chil‐ dren with and without ASD were also made for selection of items. The instrument was pilot

**•** Floor time Intervention: Floor time is a comprehensive program for infants, young chil‐ dren, and families with a variety of developmental challenges including ASD. The pro‐ gram aims at enhancing the functional emotional developmental levels and creating those learning relationships that will help the child move ahead in social skills acquisition. Floor time can be tailored to suit the individual needs of children with ASD. Floor time approach was used for treatment in the study. As stated earlier, Floor time approach helps an infant/young child reach the 6 milestones crucial for development of social be‐ havior, namely, self regulation; intimacy; two way communication; complex communica‐ tion; emotional ideas,; and emotional thinking. However, in this study, the treatment was directed toward achievement of 4 milestones – Turn taking (a component skill in intima‐ cy), Two way communication, Understanding of cause and effect relationship (an impor‐

proves by providing the child the opportunity to explore the environment.

into logical sequences and play, and imagination is also more rational.

tested on children with ASD belonging to the same age group as the subjects.

tests. The instrument measured social behaviour under 4 domains –

The intervention started after assessing the children's baseline behavior on BSFS. The 26 children were then randomly assigned to experimental and control groups so that both groups had 13 children each. As per the recommended floor time protocol, the researchers observed each child in the experimental group to determine his or her current emotional level, before the commencement of intervention. Each child in the experimental group re‐ ceived 20 sessions of floor time intervention. Each session was of 30 minutes duration. Each session included at least one activity relevant to the pre selected social skills. The sessions started by getting the child's attention by showing a desired object. The researchers used word and simple phrases to describe each activity. The activities were done as given below, and parents were encouraged to observe the sessions.

**•** Building a block tower began by demonstrating how to make a tower from the four blocks provided on the floor. The child was then asked to lay a block over the one put by the adult. Subsequently, the adult would put another block over it. The adult would then prompt the child to take his or her turn to put a block on top. The activity was repeated with a peer. Now the peer would take the adult's role. The adult would call out each child's name and say ' your turn now ', as they put one block over the other to make a block tower.


**Figure 1.** Block tower activity

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**Figure 2.** Picture matching


While the experimental group children received floor time intervention, the children in the control group received the usual early intervention sessions provided in their educational settings. Post intervention, BSFS was administered again.

Figures 1 to 7 illustrate some of the floor time activities done with the children.

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**Figure 1.** Block tower activity

**•** A number of colorful beads were placed on the floor along with a string for the bead stringing activity. The task was first demonstrated, and then used to encourage the child to take turn with an adult and later with a peer in slipping a bead through the string.

**•** The ' ball rolling ' activity was done by rolling the ball to a child and asking him or her o roll it back to the adult. In case of 5 or 6 year old children, a slight variation was made. The activity was introduced with a peer. Both the child and peer were asked to take turns

**•** Throwing the ball in the bucket required that the child identify the bucket first. Subse‐ quently, the task was demonstrated before the child taking turn with the adult and with

**•** Cause and effect activities such as ringing a bell (to produce sound), squeezing a sponge (for water to drip), and opening a box (to get what is inside) were demonstrated and sub‐ sequently, taught with prompts and cues. Some fun activities such as blowing soap bub‐

**•** Calling out the child's name, seeking his attention by showing a preferred object or toy helped in initiating two-way communication. Preferred activities served a dual purpose. They could get the child's attention, but they were also helpful in teaching the child a way to communicate. The adult would have a picture of the preferred activity or toy. The child would be asked to point or pick up the picture in order to get the activity. The adult also used facial expression cards to help the child understand what each expression meant.

**•** Pretend play was a strong medium for teaching emotional thinking. Pretend play was en‐ couraged using a variety of toys such as dolls, telephone, car, kitchen set, and doctor set etc. The adult would pretend to call the child, and ask the child to pick up the phone and say something. While the child was holding the doll, the adult would prompt him or her to hug and kiss the doll. If the child put the doll away, the adult would convey in appro‐ priate tone and affect how sad the doll was feeling. The child would then be prompted to

**•** Taking the lead from the child, the adult would stand at the window if the child was

**•** Though all activities were pre-planned, the adult would at times digress to include activi‐

While the experimental group children received floor time intervention, the children in the control group received the usual early intervention sessions provided in their educational

standing there. The adult would then softly describe what they could both see.

Figures 1 to 7 illustrate some of the floor time activities done with the children.

ties that suited the need of the child on a given day.

settings. Post intervention, BSFS was administered again.

in throwing the ball to the adult and to each other.

bles were also included as soap bubbles excited the children.

peer to throw a ball in the bucket.

704 Recent Advances in Autism Spectrum Disorders - Volume I

hold the doll again.

**Figure 2.** Picture matching

**Figure 5.** Teaching facial expression

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**Figure 6.** Choice of play things

**Figure 3.** Getting a child's attention

**Figure 4.** Pretend play with doll

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**Figure 5.** Teaching facial expression

**Figure 3.** Getting a child's attention

706 Recent Advances in Autism Spectrum Disorders - Volume I

**Figure 4.** Pretend play with doll

**Figure 6.** Choice of play things

Figure 7. Activity with peer

as the selection of children was random. Table 1 presents the details.

performance of each child at pre and post intervention conditions

Figure 8. Comparison of individual performance on BSFS

turn taking skill is provided by Figure 9.

Figure 9. Comparison of individual performance on turn taking

**Figure 9.** Comparison of individual performance on turn taking

Figure 10. comparioson of individual performance on cause and effect relationship

relationship in children with ASD.

**0**

**5**

**10**

**15**

**20**

**25**

**30**

**Figure 8.** Comparison of individual performance on BSFS

Post test 48.38 13 Table 1. Comparison of Composite Mean Scores on BSFS at Pre and Post Tests

increased post intervention [48.38]. This increase was significant as evident from the obtained

The study was conducted to establish the efficacy of floor time for development of social behavior in pre-school children with ASD. The children who received intervention showed a qualitative change in their interactive behavior. A comparison of their composite mean score on BSFS at baseline with that at post intervention showed a significant difference. The data was analyzed using t-test,

Pre test 34.92 13 12 9.56 p< .0001

The statistical analysis of data indicated the overall effectiveness of floor time. The average score on BSFS at baseline [34.92]

t-value [9.56, p<.0001]. That the intervention was effective for all children in the group may be seen from Figure 8 which shows the

From Figure 8 it is evident that floor time intervention enhanced the social behavior of children, though some gained more from the treatment than others. This variance may be due to initial intra group differences in the children's functioning levels.

From Figure 8 it is evident that floor time intervention enhanced the social behavior of chil‐ dren, though some gained more from the treatment than others. This variance may be due

**1 2 3 4 5 6 7 8 9 10 11 12 13 pre test post test**

Children's scores on selected components of BSFS of turn taking, two way communication, cause and effect and emotional thinking were analyzed individually. On Turn taking skill, the baseline mean [12,38] was significantly lower than the mean score [17.69]

Children's scores on selected components of BSFS of turn taking, two way communication, cause and effect and emotional thinking were analyzed individually. On Turn taking skill, the baseline mean [12,38] was significantly lower than the mean score [17.69] post interven‐ tion. The derived t-value [5.02] was statistically significant (p<.0002]. An illustration of each post intervention. The derived t-value [5.02] was statistically child's performance on turn taking skill is provided by Figure 9. significant (p<.0002]. An illustration of each child's performance on

It is evident from Figure 9 that the treatment was effective for all children in the experimental group. All of them gained significantly, except child no. 7 who showed a marginal improvement only. The children's ability to understand the relationship between cause and its effect also improved. Their mean performance on this sub skill post intervention [13.30] was higher than the baseline [8.61]. The derived t-value was significant [7.17, p<.0001]. Each child's performance on cause and effect is depicted in figure 10. The data indicates the effectiveness of floor time as a method to develop the understanding of cause and effect

It is evident from Figure 9 that the treatment was effective for all children in the experimen‐ tal group. All of them gained significantly, except child no. 7 who showed a marginal im‐ provement only. The children's ability to understand the relationship between cause and its

**1 2 3 4 5 6 7 8 9 10 11 12 13 pre test post test**

When performances on two-way communication skills were compared, a similar trend was evident. The mean score at baseline [6.31] was lower than that post intervention [8.69] and the difference was statistically significant (t=5.72, p<.0001]. Individually too,

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

children improved as may be seen from figure 11. All children gained on the ability for two-way communication.

to initial intra group differences in the children's functioning levels.

**Mean N df t-value Significance** 

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**8. Results** 

**Figure 7.** Activity with peer

#### **8. Results**

The study was conducted to establish the efficacy of floor time for development of social behavior in pre-school children with ASD. The children who received intervention showed a qualitative change in their interactive behavior. A comparison of their compo‐ site mean score on BSFS at baseline with that at post intervention showed a significant difference. The data was analyzed using t-test, as the selection of children was random. Table 1 presents the details.


**Table 1.** Comparison of Composite Mean Scores on BSFS at Pre and Post Tests

The statistical analysis of data indicated the overall effectiveness of floor time. The average score on BSFS at baseline [34.92] increased post intervention [48.38]. This increase was sig‐ nificant as evident from the obtained t-value [9.56, p<.0001]. That the intervention was effec‐ tive for all children in the group may be seen from Figure 8 which shows the performance of each child at pre and post intervention conditions

The study was conducted to establish the efficacy of floor time for development of social behavior in pre-school children with ASD. The children who received intervention showed a qualitative change in their interactive behavior. A comparison of their composite mean score on BSFS at baseline with that at post intervention showed a significant difference. The data was analyzed using t-test,

Pre test 34.92 13 12 9.56 p< .0001

The statistical analysis of data indicated the overall effectiveness of floor time. The average score on BSFS at baseline [34.92]

**Mean N df t-value Significance** 

Figure 8. Comparison of individual performance on BSFS **Figure 8.** Comparison of individual performance on BSFS

turn taking skill is provided by Figure 9.

relationship in children with ASD.

as the selection of children was random. Table 1 presents the details.

performance of each child at pre and post intervention conditions

Post test 48.38 13 Table 1. Comparison of Composite Mean Scores on BSFS at Pre and Post Tests

Figure 7. Activity with peer

**8. Results** 

**Figure 7.** Activity with peer

708 Recent Advances in Autism Spectrum Disorders - Volume I

Table 1 presents the details.

Post test 48.38 13

**Table 1.** Comparison of Composite Mean Scores on BSFS at Pre and Post Tests

each child at pre and post intervention conditions

The study was conducted to establish the efficacy of floor time for development of social behavior in pre-school children with ASD. The children who received intervention showed a qualitative change in their interactive behavior. A comparison of their compo‐ site mean score on BSFS at baseline with that at post intervention showed a significant difference. The data was analyzed using t-test, as the selection of children was random.

Pre test 34.92 13 12 9.56 p< .0001

The statistical analysis of data indicated the overall effectiveness of floor time. The average score on BSFS at baseline [34.92] increased post intervention [48.38]. This increase was sig‐ nificant as evident from the obtained t-value [9.56, p<.0001]. That the intervention was effec‐ tive for all children in the group may be seen from Figure 8 which shows the performance of

**Mean N df t-value Significance**

**8. Results**

From Figure 8 it is evident that floor time intervention enhanced the social behavior of children, though some gained more from the treatment than others. This variance may be due to initial intra group differences in the children's functioning levels. Children's scores on selected components of BSFS of turn taking, two way communication, cause and effect and emotional thinking were analyzed individually. On Turn taking skill, the baseline mean [12,38] was significantly lower than the mean score [17.69] From Figure 8 it is evident that floor time intervention enhanced the social behavior of chil‐ dren, though some gained more from the treatment than others. This variance may be due to initial intra group differences in the children's functioning levels.

Children's scores on selected components of BSFS of turn taking, two way communication, cause and effect and emotional thinking were analyzed individually. On Turn taking skill, the baseline mean [12,38] was significantly lower than the mean score [17.69] post interven‐ tion. The derived t-value [5.02] was statistically significant (p<.0002]. An illustration of each post intervention. The derived t-value [5.02] was statistically child's performance on turn taking skill is provided by Figure 9. significant (p<.0002]. An illustration of each child's performance on

Figure 9. Comparison of individual performance on turn taking **Figure 9.** Comparison of individual performance on turn taking

Figure 10. comparioson of individual performance on cause and effect relationship

It is evident from Figure 9 that the treatment was effective for all children in the experimental group. All of them gained significantly, except child no. 7 who showed a marginal improvement only. The children's ability to understand the relationship between cause and its effect also improved. Their mean performance on this sub skill post intervention [13.30] was higher than the baseline [8.61]. The derived t-value was significant [7.17, p<.0001]. Each child's performance on cause and effect is depicted in figure 10. The data indicates the effectiveness of floor time as a method to develop the understanding of cause and effect It is evident from Figure 9 that the treatment was effective for all children in the experimen‐ tal group. All of them gained significantly, except child no. 7 who showed a marginal im‐ provement only. The children's ability to understand the relationship between cause and its

When performances on two-way communication skills were compared, a similar trend was evident. The mean score at baseline [6.31] was lower than that post intervention [8.69] and the difference was statistically significant (t=5.72, p<.0001]. Individually too,

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

children improved as may be seen from figure 11. All children gained on the ability for two-way communication.

turn taking skill is provided by Figure 9.

relationship in children with ASD.

**0**

**10**

**15**

**20**

**25**

**30**

effect also improved. Their mean performance on this sub skill post intervention [13.30] was higher than the baseline [8.61]. The derived t-value was significant [7.17, p<.0001]. Each child's performance on cause and effect is depicted in figure 10. The data indicates the effec‐ tiveness of floor time as a method to develop the understanding of cause and effect relation‐ ship in children with ASD. Figure 9. Comparison of individual performance on turn taking It is evident from Figure 9 that the treatment was effective for all children in the experimental group. All of them gained significantly, except child no. 7 who showed a marginal improvement only. The children's ability to understand the relationship **1 2 3 4 5 6 7 8 9 10 11 12 13 pre test post test**

between cause and its effect also improved. Their mean performance on this sub skill post intervention [13.30] was higher than the baseline [8.61]. The derived t-value was significant [7.17, p<.0001]. Each child's performance on cause and effect is depicted in figure 10. The data indicates the effectiveness of floor time as a method to develop the understanding of cause and effect

post intervention. The derived t-value [5.02] was statistically significant (p<.0002]. An illustration of each child's performance on

Figure 11.Comparison of individual performance on two-way communication

Figure 11.Comparison of individual performance on two-way communication

Figure 12.Comparison of individual performance on emotional thinking

group. The data analysis is presented in Table 2.

Figure 12.Comparison of individual performance on emotional thinking

**Figure 12.** Comparison of individual performance on emotional thinking

group. The data analysis is presented in Table 2.

group. The data analysis is presented in Table 2.

**0**

**2**

**4**

**6**

**0**

**8**

**2**

**10**

**4**

**12**

**6**

**14**

**10**

**12**

**14**

**8**

turn taking, two-way communication and understanding of cause and effect relationship.

**Figure 11.** Comparison of individual performance on two-way communication

turn taking, two-way communication and understanding of cause and effect relationship.

Lastly, when the data from BSFS were analyzed for performance on emotional thinking, a significant gain was seen in this area too. The difference between baseline mean score [7.38] and post intervention mean score [8.84] was significant (t-value=3.5, p<.004]. Though this difference was significant when means were compared, individually all children did not gain from the intervention. Whereas most children showed an enhancement in emotional thinking from pre to post intervention, performance of some remained the same as what it was at baseline. Figure 12 presents the data on emotional thinking. Since, emotional thinking is the last and the most complex of the six milestones; it is possible that these children required more time to achieve this skill than what was given during the 20 sessions of intervention. However, these children improved their performance on the earlier sub-skills of

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

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Lastly, when the data from BSFS were analyzed for performance on emotional thinking, a significant gain was seen in this area too. The difference between baseline mean score [7.38] and post intervention mean score [8.84] was significant (t-value=3.5, p<.004]. Though this difference was significant when means were compared, individually all children did not gain from the intervention. Whereas most children showed an enhancement in emotional thinking from pre to post intervention, performance of some remained the same as what it was at baseline. Figure 12 presents the data on emotional thinking. Since, emotional thinking is the last and the most complex of the six milestones; it is possible that these children required more time to achieve this skill than what was given during the 20 sessions of intervention. However, these children improved their performance on the earlier sub-skills of

The second objective of the study was to compare the performance of children in the experimental group with that of those in control group. As mentioned earlier, the participant children were randomly selected from 5 pre-schools and intervention clinics. Hence, when the study commenced all children were on some kind of early intervention program. The study, in effect, determined the efficacy of floor time in comparison with other early intervention strategies. In order to do this, the post intervention performance on BSFS by both groups was analyzed. The mean score of experimental group was compared with that of control

 **Mean N df t-value Significance**  Experimental 48.38 13 24 3.08 p<.0.005

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

The second objective of the study was to compare the performance of children in the experimental group with that of those in control group. As mentioned earlier, the participant children were randomly selected from 5 pre-schools and intervention clinics. Hence, when the study commenced all children were on some kind of early intervention program. The study, in effect, determined the efficacy of floor time in comparison with other early intervention strategies. In order to do this, the post intervention performance on BSFS by both groups was analyzed. The mean score of experimental group was compared with that of control

The second objective of the study was to compare the performance of children in the experi‐ mental group with that of those in control group. As mentioned earlier, the participant chil‐ dren were randomly selected from 5 pre-schools and intervention clinics. Hence, when the study commenced all children were on some kind of early intervention program. The study, in effect, determined the efficacy of floor time in comparison with other early intervention strategies. In order to do this, the post intervention performance on BSFS by both groups was analyzed. The mean score of experimental group was compared with that of control

> **Mean N df t-value Significance**  Experimental 48.38 13 24 3.08 p<.0.005

Figure 10. comparioson of individual performance on cause and effect relationship **Figure 10.** comparioson of individual performance on cause and effect relationship

[6.31] was lower than that post intervention [8.69] and the difference was statistically significant (t=5.72, p<.0001]. Individually too, children improved as may be seen from figure 11. All children gained on the ability for two-way communication. When performances on two-way communication skills were compared, a similar trend was evident. The mean score at baseline [6.31] was lower than that post intervention [8.69] and the difference was statistically significant (t=5.72, p<.0001]. Individually too, children im‐ proved as may be seen from figure 11. All children gained on the ability for two-way com‐ munication.

When performances on two-way communication skills were compared, a similar trend was evident. The mean score at baseline

Lastly, when the data from BSFS were analyzed for performance on emotional thinking, a significant gain was seen in this area too. The difference between baseline mean score [7.38] and post intervention mean score [8.84] was significant (t-value=3.5, p<.004]. Though this difference was significant when means were compared, individually all children did not gain from the intervention. Whereas most children showed an enhancement in emotional thinking from pre to post intervention, performance of some remained the same as what it was at baseline. Figure 12 presents the data on emotional thinking. Since, emotional think‐ ing is the last and the most complex of the six milestones; it is possible that these children required more time to achieve this skill than what was given during the 20 sessions of inter‐ vention. However, these children improved their performance on the earlier sub-skills of turn taking, two-way communication and understanding of cause and effect relationship.

Figure 11.Comparison of individual performance on two-way communication **Figure 11.** Comparison of individual performance on two-way communication last and the most complex of the six milestones; it is possible that these children required more time to achieve this skill than what was given during the 20 sessions of intervention. However, these children improved their performance on the earlier sub-skills of turn taking, two-way communication and understanding of cause and effect relationship.

effect also improved. Their mean performance on this sub skill post intervention [13.30] was higher than the baseline [8.61]. The derived t-value was significant [7.17, p<.0001]. Each child's performance on cause and effect is depicted in figure 10. The data indicates the effec‐ tiveness of floor time as a method to develop the understanding of cause and effect relation‐

**1 2 3 4 5 6 7 8 9 10 11 12 13 pre test post test**

It is evident from Figure 9 that the treatment was effective for all children in the experimental group. All of them gained significantly, except child no. 7 who showed a marginal improvement only. The children's ability to understand the relationship between cause and its effect also improved. Their mean performance on this sub skill post intervention [13.30] was higher than the baseline [8.61]. The derived t-value was significant [7.17, p<.0001]. Each child's performance on cause and effect is depicted in figure 10. The data indicates the effectiveness of floor time as a method to develop the understanding of cause and effect

When performances on two-way communication skills were compared, a similar trend was evident. The mean score at baseline [6.31] was lower than that post intervention [8.69] and the difference was statistically significant (t=5.72, p<.0001]. Individually too,

When performances on two-way communication skills were compared, a similar trend was evident. The mean score at baseline [6.31] was lower than that post intervention [8.69] and the difference was statistically significant (t=5.72, p<.0001]. Individually too, children im‐ proved as may be seen from figure 11. All children gained on the ability for two-way com‐

Lastly, when the data from BSFS were analyzed for performance on emotional thinking, a significant gain was seen in this area too. The difference between baseline mean score [7.38] and post intervention mean score [8.84] was significant (t-value=3.5, p<.004]. Though this difference was significant when means were compared, individually all children did not gain from the intervention. Whereas most children showed an enhancement in emotional thinking from pre to post intervention, performance of some remained the same as what it was at baseline. Figure 12 presents the data on emotional thinking. Since, emotional think‐ ing is the last and the most complex of the six milestones; it is possible that these children required more time to achieve this skill than what was given during the 20 sessions of inter‐ vention. However, these children improved their performance on the earlier sub-skills of turn taking, two-way communication and understanding of cause and effect relationship.

**1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test**

children improved as may be seen from figure 11. All children gained on the ability for two-way communication.

post intervention. The derived t-value [5.02] was statistically significant (p<.0002]. An illustration of each child's performance on

ship in children with ASD.

munication.

relationship in children with ASD.

**0**

**5**

**10**

**15**

**20**

**25**

**30**

Figure 9. Comparison of individual performance on turn taking

710 Recent Advances in Autism Spectrum Disorders - Volume I

Figure 10. comparioson of individual performance on cause and effect relationship

**Figure 10.** comparioson of individual performance on cause and effect relationship

turn taking skill is provided by Figure 9.

Lastly, when the data from BSFS were analyzed for performance on emotional thinking, a significant gain was seen in this area too. The difference between baseline mean score [7.38] and post intervention mean score [8.84] was significant (t-value=3.5, p<.004].

remained the same as what it was at baseline. Figure 12 presents the data on emotional thinking. Since, emotional thinking is the

**2** Figure 12.Comparison of individual performance on emotional thinking **Figure 12.** Comparison of individual performance on emotional thinking

group. The data analysis is presented in Table 2.

Figure 12.Comparison of individual performance on emotional thinking The second objective of the study was to compare the performance of children in the experimental group with that of those in control group. As mentioned earlier, the participant children were randomly selected from 5 pre-schools and intervention clinics. Hence, when the study commenced all children were on some kind of early intervention program. The study, in effect, determined the efficacy of floor time in comparison with other early intervention strategies. In order to do this, the post intervention **0 1 2 3 4 5 6 7 8 9 10 11 12 13 Pre test Post test** The second objective of the study was to compare the performance of children in the experimental group with that of those in control group. As mentioned earlier, the participant children were randomly selected from 5 pre-schools and intervention clinics. Hence, when the study commenced all children were on some kind of early intervention program. The study, in effect, determined the efficacy of floor time in comparison with other early intervention strategies. In order to do this, the post intervention performance on BSFS by both groups was analyzed. The mean score of experimental group was compared with that of control group. The data analysis is presented in Table 2.  **Mean N df t-value Significance**  Experimental 48.38 13 24 3.08 p<.0.005 The second objective of the study was to compare the performance of children in the experi‐ mental group with that of those in control group. As mentioned earlier, the participant chil‐ dren were randomly selected from 5 pre-schools and intervention clinics. Hence, when the study commenced all children were on some kind of early intervention program. The study, in effect, determined the efficacy of floor time in comparison with other early intervention strategies. In order to do this, the post intervention performance on BSFS by both groups was analyzed. The mean score of experimental group was compared with that of control group. The data analysis is presented in Table 2.

performance on BSFS by both groups was analyzed. The mean score of experimental group was compared with that of control

 **Mean N df t-value Significance**  Experimental 48.38 13 24 3.08 p<.0.005


Control 37.46 13 Table 2. Comparison of Post test performance of experimental and control groups

with ASD. Figure 13 provides a graphic representation of this difference

Figure 13.Comparison of post intervention performance of experimental and control groups

(C&E), and emotional thinking (ET), within BSFS is presented in Figure 14.

Figure 14.Comparison of experimental and control group on sub skills of BSFS

**Figure 14.** Comparison of experimental and control group on sub skills of BSFS

group.

**9. Discussion** 

**9. Discussion**

Comparison of post intervention mean scores of experimental and control groups showed a significant difference between the two, in favour of the experimental group. The resultant t- value [3.08] was statistically significant (p<.005]. This indicated that in comparison to other measures for early intervention, floor time was more effective in development of social behavior of children

It is evident from Figure 13 that except for child no. 3 and child no. 5, all children in experiment group achieved higher scores on BSFS than the control group children. Most children's scored significantly higher than their control group peers. A comparative analysis of both group's mean performance on each sub skill i.e. turn taking (TT), two-way communication (TWC), cause and effect

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**1 2 3 4 5 6 7 8 9 10 11 12 13**

**Experimental Control**

The children who received floor time intervention performed better on an average than those who were in the control group. However, the performance gap between the two groups was not uniform across all sub skills. On emotional thinking skill, the average performance of both groups was nearly same with control group's mean less than 2 points below that of experimental

TT TWC C & E ET Experimental Control

Unlike neuro-typical children who learn how to be social and interactive by watching how others talk, play and relate to each other, enjoy the give-and-take of social engagement and initiate, maintain and respond to interactions with others, children with autism often do not show the expected development of early social interaction skills. Promoting the social development of infants and toddlers with ASD is one of the primary goals of early intervention services, as is facilitating the ability of young children with

Unlike neuro-typical children who learn how to be social and interactive by watching how others talk, play and relate to each other, enjoy the give-and-take of social engage‐ ment and initiate, maintain and respond to interactions with others, children with autism often do not show the expected development of early social interaction skills. Promoting the social development of infants and toddlers with ASD is one of the primary goals of early intervention services, as is facilitating the ability of young children with social de‐ lays to develop appropriate friendships. With early and intensive intervention, the seem‐ ingly pervasive social skill deficits of many children with ASD can be remediated[21]. To successfully target these important skills, intervention efforts, even within early interven‐ tion, should include: (a) regular access to typical peers, (b) thoughtful planning of mean‐ ingful social situations embedded throughout the day, (c) the use of "social" toys, (d) multiple-setting opportunities (home inclusive, community-based) to practice emerging social skills, and (e) intensive data collection in order to make midcourse corrections to existing intervention plans [22]. Poor social skills are an impediment to child's success in classroom, and can also be the cause of behavioral problem. Accordingly, teaching social skills is a common educational objective for children who have autism [23]. However, while teaching variables such as age, developmental and functional levels and sensory profile of each should be considered. Floor time which is based on the developmental approach takes care of the child's developmental level and emphasizes building the mile‐ stones that the child may have missed during his or her period of growth. Rather than focusing on teaching a child to speak a few words to interact, Greenspan suggests that the child's gestural system should be worked upon first for language to flow in natural‐ ly rather than by rote, thus focusing on the developmental ladder. As the child climbs the developmental ladder he or she becomes more and more regulated and forms a

**Table 2.** Comparison of Post test performance of experimental and control groups

with ASD. Figure 13 provides a graphic representation of this difference

Figure 14.Comparison of experimental and control group on sub skills of BSFS

group.

**9. Discussion** 

0

14

Comparison of post intervention mean scores of experimental and control groups showed a significant difference between the two, in favour of the experimental group. The resultant tvalue [3.08] was statistically significant (p<.005]. This indicated that in comparison to other measures for early intervention, floor time was more effective in development of social be‐ havior of children with ASD. Figure 13 provides a graphic representation of this difference Control 37.46 13 Table 2. Comparison of Post test performance of experimental and control groups

Comparison of post intervention mean scores of experimental and control groups showed a significant difference between the two, in favour of the experimental group. The resultant t- value [3.08] was statistically significant (p<.005]. This indicated that in comparison to other measures for early intervention, floor time was more effective in development of social behavior of children

Figure 13.Comparison of post intervention performance of experimental and control groups **Figure 13.** Comparison of post intervention performance of experimental and control groups

It is evident from Figure 13 that except for child no. 3 and child no. 5, all children in experiment group achieved higher scores on BSFS than the control group children. Most children's scored significantly higher than their control group peers. A comparative analysis of both group's mean performance on each sub skill i.e. turn taking (TT), two-way communication (TWC), cause and effect (C&E), and emotional thinking (ET), within BSFS is presented in Figure 14. 16 18 20 It is evident from Figure 13 that except for child no. 3 and child no. 5, all children in experi‐ ment group achieved higher scores on BSFS than the control group children. Most children's scored significantly higher than their control group peers. A comparative analysis of both group's mean performance on each sub skill i.e. turn taking (TT), two-way communication (TWC), cause and effect (C&E), and emotional thinking (ET), within BSFS is presented in Figure 14.

2 4 6 8 10 12 The children who received floor time intervention performed better on an average than those who were in the control group. However, the performance gap between the two groups was not uniform across all sub skills. On emotional thinking skill, the average per‐ formance of both groups was nearly same with control group's mean less than 2 points be‐ low that of experimental group.

> TT TWC C & E ET Experimental Control

The children who received floor time intervention performed better on an average than those who were in the control group. However, the performance gap between the two groups was not uniform across all sub skills. On emotional thinking skill, the average performance of both groups was nearly same with control group's mean less than 2 points below that of experimental

Unlike neuro-typical children who learn how to be social and interactive by watching how others talk, play and relate to each other, enjoy the give-and-take of social engagement and initiate, maintain and respond to interactions with others, children with autism often do not show the expected development of early social interaction skills. Promoting the social development of infants and toddlers with ASD is one of the primary goals of early intervention services, as is facilitating the ability of young children with

The children who received floor time intervention performed better on an average than those who were in the control group. However, the performance gap between the two groups was not uniform across all sub skills. On emotional thinking skill, the average performance of both groups was nearly same with control group's mean less than 2 points below that of experimental

analysis of both group's mean performance on each sub skill i.e. turn taking (TT), two-way communication (TWC), cause and effect

**1 2 3 4 5 6 7 8 9 10 11 12 13**

**Experimental Control**

Comparison of post intervention mean scores of experimental and control groups showed a significant difference between the two, in favour of the experimental group. The resultant t- value [3.08] was statistically significant (p<.005]. This indicated that in comparison to other measures for early intervention, floor time was more effective in development of social behavior of children

Figure 14.Comparison of experimental and control group on sub skills of BSFS **Figure 14.** Comparison of experimental and control group on sub skills of BSFS

Control 37.46 13 Table 2. Comparison of Post test performance of experimental and control groups

with ASD. Figure 13 provides a graphic representation of this difference

Figure 13.Comparison of post intervention performance of experimental and control groups

(C&E), and emotional thinking (ET), within BSFS is presented in Figure 14.

#### group. **9. Discussion**

**Mean N df t-value Significance**

Experimental 48.38 13 24 3.08 p<.0.005

Comparison of post intervention mean scores of experimental and control groups showed a significant difference between the two, in favour of the experimental group. The resultant tvalue [3.08] was statistically significant (p<.005]. This indicated that in comparison to other measures for early intervention, floor time was more effective in development of social be‐ havior of children with ASD. Figure 13 provides a graphic representation of this difference

Comparison of post intervention mean scores of experimental and control groups showed a significant difference between the two, in favour of the experimental group. The resultant t- value [3.08] was statistically significant (p<.005]. This indicated that in comparison to other measures for early intervention, floor time was more effective in development of social behavior of children

It is evident from Figure 13 that except for child no. 3 and child no. 5, all children in experiment group achieved higher scores on BSFS than the control group children. Most children's scored significantly higher than their control group peers. A comparative analysis of both group's mean performance on each sub skill i.e. turn taking (TT), two-way communication (TWC), cause and effect

It is evident from Figure 13 that except for child no. 3 and child no. 5, all children in experi‐ ment group achieved higher scores on BSFS than the control group children. Most children's scored significantly higher than their control group peers. A comparative analysis of both group's mean performance on each sub skill i.e. turn taking (TT), two-way communication (TWC), cause and effect (C&E), and emotional thinking (ET), within BSFS is presented in

The children who received floor time intervention performed better on an average than those who were in the control group. However, the performance gap between the two groups was not uniform across all sub skills. On emotional thinking skill, the average per‐ formance of both groups was nearly same with control group's mean less than 2 points be‐

**1 2 3 4 5 6 7 8 9 10 11 12 13**

**Experimental Control**

The children who received floor time intervention performed better on an average than those who were in the control group. However, the performance gap between the two groups was not uniform across all sub skills. On emotional thinking skill, the average performance of both groups was nearly same with control group's mean less than 2 points below that of experimental

TT TWC C & E ET Experimental Control

Unlike neuro-typical children who learn how to be social and interactive by watching how others talk, play and relate to each other, enjoy the give-and-take of social engagement and initiate, maintain and respond to interactions with others, children with autism often do not show the expected development of early social interaction skills. Promoting the social development of infants and toddlers with ASD is one of the primary goals of early intervention services, as is facilitating the ability of young children with

Control 37.46 13

712 Recent Advances in Autism Spectrum Disorders - Volume I

**Table 2.** Comparison of Post test performance of experimental and control groups

Control 37.46 13 Table 2. Comparison of Post test performance of experimental and control groups

with ASD. Figure 13 provides a graphic representation of this difference

Figure 13.Comparison of post intervention performance of experimental and control groups

**Figure 13.** Comparison of post intervention performance of experimental and control groups

(C&E), and emotional thinking (ET), within BSFS is presented in Figure 14.

Figure 14.Comparison of experimental and control group on sub skills of BSFS

low that of experimental group.

group.

**9. Discussion** 

Figure 14.

**9. Discussion**  Unlike neuro-typical children who learn how to be social and interactive by watching how others talk, play and relate to each other, enjoy the give-and-take of social engagement and initiate, maintain and respond to interactions with others, children with autism often do not show the expected development of early social interaction skills. Promoting the social development of infants and toddlers with ASD is one of the primary goals of early intervention services, as is facilitating the ability of young children with Unlike neuro-typical children who learn how to be social and interactive by watching how others talk, play and relate to each other, enjoy the give-and-take of social engage‐ ment and initiate, maintain and respond to interactions with others, children with autism often do not show the expected development of early social interaction skills. Promoting the social development of infants and toddlers with ASD is one of the primary goals of early intervention services, as is facilitating the ability of young children with social de‐ lays to develop appropriate friendships. With early and intensive intervention, the seem‐ ingly pervasive social skill deficits of many children with ASD can be remediated[21]. To successfully target these important skills, intervention efforts, even within early interven‐ tion, should include: (a) regular access to typical peers, (b) thoughtful planning of mean‐ ingful social situations embedded throughout the day, (c) the use of "social" toys, (d) multiple-setting opportunities (home inclusive, community-based) to practice emerging social skills, and (e) intensive data collection in order to make midcourse corrections to existing intervention plans [22]. Poor social skills are an impediment to child's success in classroom, and can also be the cause of behavioral problem. Accordingly, teaching social skills is a common educational objective for children who have autism [23]. However, while teaching variables such as age, developmental and functional levels and sensory profile of each should be considered. Floor time which is based on the developmental approach takes care of the child's developmental level and emphasizes building the mile‐ stones that the child may have missed during his or her period of growth. Rather than focusing on teaching a child to speak a few words to interact, Greenspan suggests that the child's gestural system should be worked upon first for language to flow in natural‐ ly rather than by rote, thus focusing on the developmental ladder. As the child climbs the developmental ladder he or she becomes more and more regulated and forms a

sense of self. In the study the authors chose age and functionally appropriate activities for helping a child achieve the given milestones for social behavior. The individual ses‐ sions during which the adult followed the child's lead, prompted and encouraged the child effort to participate, and provided the opportunity to practice the skill with a peer contributed to the significant increase in each child's performance from pre to post inter‐ vention on BSFS.

**10. Conclusion**

ASD.

**Acknowledgements**

tion clinics for their support.

Rubina Lal and Rakhee Chhabria

**Author details**

**References**

Early intervention is very important for enhancing the development of infants and toddlers with disabilities, and they are especially crucial in determining the future language, social and behavioral outcomes of very young children with ASD [27]. A primary consideration of programs for young children with ASD is to provide an environment that is designed to prevent problem behaviors, promote engagement and participation, and facilitate successful interactions with typically developing peers. Getting the child to engage with materials and activities may prevent challenging behavior occurrence and promote appropriate social be‐ havior [28]. Results of this research support the above findings. Floor time principles state that development begins with a shared world between the caregiver and the young child. The goal is to help the child with ASD emerge from its own world and enter this shared world in order to develop his or her functional and emotional capacities. Floor time achieves this by encouraging child to engage in age and level appropriate play activities with adults and later with peers. The outcomes indicate the effectiveness of Floor time as a method for early intervention of children with autism. The findings of the study may be useful for fami‐ lies who are in need of evidence based and suitable early intervention for children with

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The authors wish to thank the children who participated in this study, and are grateful to the children's parents, teachers, therapists, and administrators of the schools and interven‐

[1] Autism Society of America (2006). *Defining Autism.* Available from http://

[2] American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental

[3] Young, R. Brewer, N. Pattison, C. (2003). Parental identification of early behaviora‐

labnormalities in children with autistic disorder. Autism, 7, 125-143.

Department of Special Education, SNDT Women's University, Mumbai, India

www.autismsociety.org (accessed May. 8, 2012)

Disorders (4th ed. TR). Washington DC

According to the Colorado guidelines [24] early intervention strategies must involve build‐ ing of positive relationships between adults (parents and caregivers) and the infant or tod‐ dler. The intent should be to teach the child that parents and caregivers can be relied on as stable, secure, and safe figures that provide nurturance, comfort, pleasure and guidance. De‐ veloping attachments is a challenge for a young child with ASD, so special efforts are re‐ quired, even when signs of a child's interest are not apparent. This might require that a parent or caregiver identify the activities, objects, settings, and interactions that the child finds pleasurable and provide those events and items to the child contingent on a social in‐ teraction behavior (rather than non-contingently in a manner meant to keep a child satisfied without social interaction). A tickle game might be initiated with a child and then interrupt‐ ed by the caregiver with the expectation that the child look at the adult or repeat a gesture to continue. A key objective of efforts to form positive relationships is to ensure that the inter‐ actions are pleasurable and that they are associated with the child receiving input that is consistent with needs and interests. Importantly, successful efforts to form strong, positive bonds when a child is very young result in a subsequent relationship in which an adult has considerable influence over a child's behavior and this influence can be essential for the guidance and instruction that the adult (parent or other caregiver) must provide on an ongo‐ ing basis. The floor time intervention addressed the issues mentioned above. Activities se‐ lected were simple and manageable for the children. Most activities were demonstrated before the child was required to participate. For children with autism, visually organized tasks are easier to learn [25]. During intervention the adult often provided model/picture of a task to be done e.g. block tower, completed puzzle, picture and symbol cards etc. Interven‐ tion sessions were built around child's motivation and interests. Most early intervention programs for children with ASD are based on behavioral approach and use discrete trial training. Though evaluations have shown acquisition of learning and behavioral develop‐ ment in several children [26], behavioral approach does not suit all children and families. Strict protocol of timing, intensity, structure, and quality of therapist training influences the success of behavioral interventions. In contrast, floor time encourages naturalistic interac‐ tions to develop the core skills. It takes into account the inherent bonding and affection pa‐ rents have for the child, and guides the parent to modify and channelize their interactions to suit the developmental level of the child. As stated earlier, the children selected for the study attended pre-school and intervention clinics. Thus control group children also re‐ ceived early intervention while floor time intervention was given to the experimental group. However, the experimental group children performed better on selected social skills at the end of the intervention period. The significantly higher achievement of social skills by ex‐ perimental group children may be attributed to the child-centric naturalistic interactions that occurred during the floor time intervention.
