**5. The DIR model and floor time**

with no disability enhances the quality but it should be done so that peer interaction is

**•** Program Design and Methods: A high degree of structure in the program is essential, i.e. well organized, regular and predictable, focused on specific objectives, and consistently managed. A supportive teaching environment with modeling, prompting, praise, shap‐

**•** Challenging Behaviors: A functional approach to modifying challenging behaviors in‐ cludes positive behavior support that consists of teaching alternative appropriate behav‐

**•** Personnel: Teachers and therapists should be adequately trained in working with chil‐ dren with autism and have knowledge and skills required for their special needs.

**•** Family Collaboration: Parents need information about autism and services, especially at key times like first diagnosis and school entry. Programs should include parent involve‐ ment, such as provision of support, counseling, and parent education to help the child with play, social, and communication skills development, and with management of chal‐

**•** Research and Evaluation of Program: Evaluation of treatment outcomes should be built into EI programs using systematic assessment of the child's social, cognitive, and adap‐ tive functioning before, during, and at the end of the program. Regular and systematic

Collaboration with family or parents is a component of best EI practices. Parents of children who have autism play an important role; they are critical components of the intervention process, without whom gains are unlikely to be maintained. The involvement of parents in implementing intervention strategies designed to help their autistic children has a history stretching back at least three decades [12]. Parental involvement is an integral part of the success of early intervention programs for children with autism. The collaboration between the parent and the professional working with the child in the program is critical to the effec‐

Traditionally, the EI for autism has been premised on the use of applied behavioral methods such as discrete trials. However, at times parents find the structure, organization and proto‐ col of behavioral intervention difficult to implement and maintain. Consequently, the pro‐ gram receives inadequate follow up in the child's home. There is a need for interventions that do not require a rigid structure and ensure parental involvement. Hence, in the recent years, EI practices for autism have seen a shift from behavioral methods to developmental

In a developmental approach, development of a child with autism is compared with the de‐ velopmental sequence seen in non-disabled children. Early childhood assessment tools are

ing, and generalization strategies will maximize learning.

ior and communication skills to replace challenging behaviors.

documentation of program process and outcome helps in evaluation.

adequately supported.

696 Recent Advances in Autism Spectrum Disorders - Volume I

lenging and repetitive behaviors

tiveness of programs.

**4. Developmental approach**

approaches.

The Developmental, Individual, Relationship-based (DIR) Model, designed by Stanley Greenspan in 1989, provides a framework to understand the functional emotional develop‐ ment and unique profile of every child, and a guide to create emotionally meaningful learn‐ ing interactions that promote critical functional emotional developmental capacities. The objectives of the DIR Model are to build healthy foundations for social, emotional, and intel‐ lectual capacities rather than focusing on skills and isolated behaviors [13]. The DIR de‐ scribes six milestones as crucial to a child's development. Parents and professionals involved with the child must comprehend how the milestones affect a child's emotional and intellec‐ tual growth. The six milestones, namely, Self regulation and interest, Intimacy, Two-way communication, Complex communication, Emotional ideas, and Emotional thinking, are ex‐ plained below. Individual difference is the unique biologically-based ways each child takes in, regulates, responds to, and comprehends sensations such as sound, touch, and the plan‐ ning and sequencing of actions and ideas. While children may be very hyper sensitive to touch and sound, others may be hypo sensitive, and still others seek out these sensations. Relationship is described as the learning relationships with caregivers, educators, therapists, peers, and others who tailor their affect based interactions to the child's individual differen‐ ces and developmental capacities to enable progress in mastering the essential foundations.

Floor time, is central to the DIR model of early intervention. It enables professionals and pa‐ rents to assess and implement intervention programs that address the unique developmen‐ tal needs of children with autism. The major element of this approach entails that (a) professionals do floor time with the child (b) parents observe floor time being done with their child, and (c) parents change their style of relating to the child with regard to a given milestone. Floor time is a systematic way of working with a child with autism to help him or her climb the developmental ladder. Floor time intervention aims at taking the child back to the first milestones that the child may have missed in the process of development. With the help of the therapists and parents the child works towards achieving the milestones. This is done through intensive one to one sessions for which parents share equal responsibility with the therapists. According to the DIR/Floor time framework, due to individual process‐ ing differences, children with autism do not master the early developmental milestones that are the foundations of learning. Floor time [14] describes six core developmental stages that children with autism have often missed or not mastered:

is a car garage. This idea-filled play provides a strong basis for language development. Besides learning to label things, the child now uses dialogue during play with help of the parents. Eventually, he is able to manipulate the ideas to meet his needs. When hungry, he can ask for food; if he needs help he can call his mother instead of crying. He learns about object permanence - that although not visible to him, object do not disappear. Hence, he can feel secure thinking about his parents even when they are not with him. With this ability to use symbols, the child moves on to a higher level of communication

Early Intervention of Autism: A Case for Floor Time Approach

http://dx.doi.org/10.5772/54378

699

**•** Emotional thinking: When he reaches this stage, a child is ready to connect various ideas into a logical sequence. While in the previous stage he was able to carry out symbolic ac‐ tivities, such as dressing a doll, and banging a toy car into another to simulate a crash, the child is now able to think emotionally. He may dress up the doll for a car ride. At this stage, the child is able to express a wide range of emotions, and through this learns to rec‐ ognize self. The child now comprehends concept of space and time at a personal level. For example, the child understands that grandmother's house is different from his own, or that if he grabs another child's toys, his own favorite car may later be taken away by that child. The child, by this time, is fully verbal and can use words to express ideas and feel‐

A typical floor time session is conducted in a child's naturalistic environment and requires the therapist or parent to sit on the floor and work with the child. The purpose is to help the child achieve the stages of development, by taking him back to the milestones that he may have missed. During a session, the parent or therapist follows the child's lead. This helps in establishing relationship between the child and the adult. It is this relationship that slowly enables the child to develop the basic social, emotional and communication abilities. During a floor time session the child learns to engage with others, initiate actions, make own wishes and desires known and the realization that his actions can elicit responses from others. Floor time creates opportunities for children to have dialogues, which are called circles of commu‐ nication, first without words and later with them, and eventually to imagine and think. Since floor time sessions are child-centered, the activities are motivating to the child as it is he who has chosen them. Additionally, the selecting the child's natural environment for the session also contributes to calming him and improving his comfort level. A floor time ses‐

**1.** Observation: Before starting a session, the adult observes the child. This requires watch‐ ing the child while he is in the room, observing what interests him, assessing his level of interaction – is he running around or is he sitting quietly. This observation helps the

**2.** Approach: Once the adult understands the child's level of emotional functioning, he or she joins the child in whatever the child is doing. If the child sits and merely twirls a toy, the adult follows this play behavior. However, the adult adds value to it by label‐

and awareness.

ings.

**5.1. Floor time method**

sion follows the steps given below.

adult determine the child's current emotional state.


is a car garage. This idea-filled play provides a strong basis for language development. Besides learning to label things, the child now uses dialogue during play with help of the parents. Eventually, he is able to manipulate the ideas to meet his needs. When hungry, he can ask for food; if he needs help he can call his mother instead of crying. He learns about object permanence - that although not visible to him, object do not disappear. Hence, he can feel secure thinking about his parents even when they are not with him. With this ability to use symbols, the child moves on to a higher level of communication and awareness.

**•** Emotional thinking: When he reaches this stage, a child is ready to connect various ideas into a logical sequence. While in the previous stage he was able to carry out symbolic ac‐ tivities, such as dressing a doll, and banging a toy car into another to simulate a crash, the child is now able to think emotionally. He may dress up the doll for a car ride. At this stage, the child is able to express a wide range of emotions, and through this learns to rec‐ ognize self. The child now comprehends concept of space and time at a personal level. For example, the child understands that grandmother's house is different from his own, or that if he grabs another child's toys, his own favorite car may later be taken away by that child. The child, by this time, is fully verbal and can use words to express ideas and feel‐ ings.

#### **5.1. Floor time method**

her climb the developmental ladder. Floor time intervention aims at taking the child back to the first milestones that the child may have missed in the process of development. With the help of the therapists and parents the child works towards achieving the milestones. This is done through intensive one to one sessions for which parents share equal responsibility with the therapists. According to the DIR/Floor time framework, due to individual process‐ ing differences, children with autism do not master the early developmental milestones that are the foundations of learning. Floor time [14] describes six core developmental stages that

**•** Regulation and interest in the world: Infants try and process what they see, hear, and feel. They respond to pleasant face and soothing voice. They learn to enjoy, understand and, use the pleasant feelings and sensations to calm themselves. This helps them learn to take in and respond appropriately to the world around them. This ultimately develops the

**•** Engagement and relationship: Babies learn to bond with their parents very soon. They recognize the parents' face and voice, and want to touch them or be close to them. They enjoy being cuddled and loved by their parents. This process of bonding also builds a re‐ lationship of trust between babies and their parents. This trusting relationship enables the child to become a well-adjusted adult later in his or her life. It also forms a stable base for all future relationships. The baby learns that relationships with people can be joyful.

**•** Two-way communication: Once relationship with parents is developed, the baby realizes that he or she can have an impact on parents. The baby's smile can produce a smile from the parents. If the baby reaches out to mother, she picks him or her up. The baby learns that adults can understand and respond to its communication intents and feelings. A dy‐ ad of communication starts slowly. When the baby looks at the mother and reaches out to her – the mother responds by giving eye contact and a hug. In turn the baby may smile, vocalize or touch the mother. Thus a non-verbal dialogue or a two-way communication process may be completed. The baby soon transfers this new ability to other things in the environment. He bangs a toy, it makes a noise, and if he drops his bottle, it breaks. His actions can have an impact not only on his parents but others too. Hence, two-way com‐

**•** Complex communication: The non-verbal two way communication slowly becomes com‐ plex in nature. While earlier the baby was initiating or responding to a communication by a simple gesture of reaching out or smiling, now he may run towards the mother, and squeal with pleasure. Anger and displeasure may be expressed by pulling, kicking and grabbing or throwing things. Similarly, hugs and kisses are used to express affection. Since, the baby is ambulatory by now, he may take the parent by hand and show them what he wants. Complex communication ability also aid development of creativity. The toddler adds his own ideas to the games that parents play with him. This leads to the

**•** Emotional ideas: Play is a fertile ground for ideas. Using toys and playthings, a child cre‐ ates a world where toys play roles. So, a teddy is a friend, a doll is a baby and a shoe box

munication helps babies to learn about them and about the world.

emergence of the child's own personality.

children with autism have often missed or not mastered:

698 Recent Advances in Autism Spectrum Disorders - Volume I

ability to self regulate.

A typical floor time session is conducted in a child's naturalistic environment and requires the therapist or parent to sit on the floor and work with the child. The purpose is to help the child achieve the stages of development, by taking him back to the milestones that he may have missed. During a session, the parent or therapist follows the child's lead. This helps in establishing relationship between the child and the adult. It is this relationship that slowly enables the child to develop the basic social, emotional and communication abilities. During a floor time session the child learns to engage with others, initiate actions, make own wishes and desires known and the realization that his actions can elicit responses from others. Floor time creates opportunities for children to have dialogues, which are called circles of commu‐ nication, first without words and later with them, and eventually to imagine and think. Since floor time sessions are child-centered, the activities are motivating to the child as it is he who has chosen them. Additionally, the selecting the child's natural environment for the session also contributes to calming him and improving his comfort level. A floor time ses‐ sion follows the steps given below.


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

Josefi and Ryan [17] conducted a case study on a 6 year old boy with severe autism. Video recordings of 16 sessions of play therapy with the child were analyzed qualitatively and quantitatively. The study concluded that this child was able to enter into a therapeutic rela‐ tionship and demonstrated attachment behavior towards the therapist. Key areas of im‐ provement were in the child's development of autonomy and pretend play, while ritualistic behaviors showed only mild improvement. Changes were also noted in the boy's behavior at home of increased independence and empathy. One implication of this preliminary re‐ search is that non-directive play therapy may enhance and accelerate emotional/social de‐

Early Intervention of Autism: A Case for Floor Time Approach

http://dx.doi.org/10.5772/54378

701

Children with ASD differ from one another—in the ways they engage, relate, and communi‐ cate and in the ways they respond to sensations, and plan and sequence their actions. These differences mean that each child requires an intervention approach tailored to his unique‐ ness, an intervention that must also consider the home setting. According to Costa and Wit‐ ten [18] the goals of such a program, regardless of the approach used, must be to strengthen the child's core deficits, namely: building the foundations for relating, communicating and thinking. The DIR/Floor time Model is especially beneficial to children with ASD and other

Solomon et al [19] published an evaluation of The PLAY Project Home Consultation, a wide‐ ly disseminated program that trains parents of children with autism spectrum disorders in the DIR/Floor time model. Sixty- eight children, 2 to 6 years old (average 3.7 years) complet‐ ed an 8–12 month program where parents were encouraged to deliver 15 hours per week of 1:1 interaction. Pre/post ratings of videotapes by blind raters using the Functional Emotional Assessment Scale (FEAS) showed significant increases in child subscale scores. That is, 45.5 percent of children made good to very good functional developmental progress. Overall pa‐

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 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.

children who received floor time intervention with those who did not.

velopment of children with severe autism.

developmental and/or emotional challenges.

rents' satisfaction with program was 90 percent.

**7. Method**

**7.1. Subjects**

