*3.12.2. Overview of the technique*

According to Greenspan and Wieder [84], the DIR® Model was created by Dr. Stanley Greenspan in the 1980s. The model highlights the developmental, individual differences, and relationship-based components of emotional development in children. The developmental part of the model focuses specifically on the six identified developmental levels that are required for emotional health. These hierarchical levels include: (1) self-regulation and interest in the world, (2) engaging and relating, (3) purposeful two-way communication, (4) complex communication and problem-solving, (5) using symbols and creating emotional ideas, and (6) logical thinking and building bridges between ideas.

Individual differences in the DIR® Model refer to the child-specific ways that information can be taken in and processed [84]. It is commonly understood that children with ASD are unique; with each child demonstrating individualized ways of responding to sensory input. These individual differences need to be considered when attempting to factiliate in social–emotional development.

The relationship-based component of the DIR® model refers to the use of emotional connection to foster development. Clinicians utilizing a DIR® approach need to purposefully tailor their actions and communication to engage the child in an emotional relationship [84].

Clinical application of the DIR® model occurs in what is called Floortime™. Therapists engaging in Floortime™ techniques demonstrate skills in getting to the child's level and allowing the child's actions and communications to lead the emotional relationship [84]. By engaging in the child's world, this technique postulates that you can then bring the child into a "shared world" [85]. These techniques, when employed correctly, can help the child with ASD progress through the levels of emotional development.

#### *3.12.3. Review of literature*

Research regarding DIR®/Floortime™ appears to be somewhat limited in both scope and vigor, although the research base is expanding. A pilot randomized controlled trial was completed in 2011 by Pajareya and Nopmaneejumruslers in Thailand [86]. This study utilized 32 participants that were 2–6 years old and were diagnosed with autistic disorder according to the DSM-IV. Participants were randomly assigned to the typical treatment group, or the DIR®/Floortime™—supplemented treatment group. Findings from the study revealed that DIR®/Floortime™ helped children with autism to better engage with caregivers. Additionally, the study found that engagement in DIR/Floortime™ helped parents to better play with their children with autism.

**Author details**

\*, Amy Nwora<sup>2</sup>

1 Idaho State University, Pocatello, ID, USA

2 D'Youville College, Buffalo, NY, USA

2014;**68**(Suppl 1):S1-S48

1999;**53**(6):547-558

1997;**278**(16):1321-1326

& Wilkins; 2014. pp. 35-46

of Occupational Therapy. 1998;**65**(2):81-91

\*Address all correspondence to: geebrya@isu.edu

and Theodore W. Peterson<sup>1</sup>

Occupational Therapy's Role in the Treatment of Children with Autism Spectrum Disorders

http://dx.doi.org/10.5772/intechopen.78696

21

[1] American Occupational Therapy Association. Occupational therapy practice framework: Domain and process, 3rd ed. The American Journal of Occupational Therapy

[2] Christiansen CH. Defining lives: Occupation as identity: An essay on competence, coherence, and the creation of meaning. The American Journal of Occupational Therapy.

[3] Clark F, Azen SP, Zemke R, et al. Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association.

[4] Boyt Schell BA, Gillen G, Scaffa M, Cohn E, et al. Willard and Spackman's Occupational Therapy. 12th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2014

[5] Yerxa EJ. An introduction to occupational science, a foundation for occupational therapy

[6] Law M, Steinwender S, Leclair L. Occupation, health and well-being. Canadian Journal

[7] Hooper B, Wood W. The philosophy of occupational therapy: A framework for practice. In: Boyt Schell BA, Gillen G, Scaffa M, Cohn E, editors. Willard and Spackman's Occupational Therapy. 12th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams

[8] World Health Organization. International Classification of Functioning, Disability and

[9] Fisher AG, Griswold LA. Performance skills: Implementing performance analyses to evaluate quality of occupational performance. In: Boyt Schell BA, Gillen G, Scaffa M, Cohn E, editors. Willard and Spackman's Occupational Therapy. 12th ed. Philadelphia,

in the 21st century. Occupational Therapy in Health Care. 1990;**6**(4):1-17

Health: ICF. Geneva, Switzerland: World Health Organization; 2001

PA: Wolters Kluwer Lippincott Williams & Wilkins; 2014. pp. 249-264

Bryan M. Gee<sup>1</sup>

**References**

Liao and associates completed a study involving the use of DIR®/Floortime™ at home on preschool-aged children [87]. The study had a sample of 11 young boys and their mothers. Results of the study indicated that the use of DIR®/Floortime™ significantly improved twoway communication, relationship formation, problem solving, and behavioral organization, and adaptive skills. Additionally, mothers who utilized the intervention felt that their parent–child interactions improved.

A randomized controlled trial regarding ASD and DIR®/Floortime™ was conducted by Lal and Chhabria in 2013 [88]. This study utilized a sample of 26 children aged 3–6 who were diagnosed with ASD. These children were randomly assigned to treatment and control groups, with 13 participants in each group. The treatment group received 20 sessions of DIR®/Floortime™ that lasted 30 min each, while the control group received typical early intervention services. Results of this study indicated that all children who received DIR®/Floortime™ demonstrated improved social behavior from pre-test to post-test. Comparison between the control group and treatment group from pre to posttest indicated significant differences, with the DIR®/Floortime™ group showing greater improvement.

These positive results suggest that DIR®/Floortime™ does help in promoting social–emotional growth, which can improve functional outcomes. While the evidence is positive, scope is limited, which suggests caution in application until further studies regarding efficacy can be completed.
