DIR® Dialogues: Research Supporting DIRFloortime®

DIR® Dialogues

This DIR® Dialogues panel explores the research base behind DIRFloortime®, as a follow up to a previous episode, highlighting both its strong, transdisciplinary foundations and the challenges of measuring developmental, relational change within traditional research models like randomized controlled trials (RCTs). The discussion emphasizes the need to rethink what counts as “evidence,” prioritize outcomes that reflect lived experience and long-term development, and expand research approaches to better support access, funding, and practice across ages and contexts.

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This Episode’s Guests

Dr. Pajareya’s randomized controlled trial (RCT) study from 2019 looked at children with developmental disabilities versus an autism diagnosis. Jeff says that we need more studies looking at a broader population like this. Just about all of the studies are with younger children, he said, and we know that Floortime is used with older children. He says we need research to support that. For Jeff, both from a clinical/research and from a leadership standpoint, he wishes there was more connection to, and being able to communicate about, the research that does exist along with getting more research about specific clinical practice and across different diagnoses and ages. There’s a lot to do, he urges.

When Jeff started with ICDL 13 years ago, he’d get beaten up by the ABA (Applied Behaviour Analysis) advocates that there was no empirical research for Floortime. He hasn’t heard that anymore for the last 5 or 6 years, but there’s still a long way to go and we need to get more consistent research happening. It is a challenge because Floortime is a transdisciplinary practice. It’s not one profession that’s pushing it for their own financial reasons. The ABA community has a real financial investment in ABA research. That’s a different infrastructure. We don’t have that infrastructure because DIR® is a transdisciplinary approach, so that research has to come from the practitioners wanting to see that happen, and not just because there’s a financial motivation, Jeff asserts.

Randomized Controlled Trials

Amanda knows the hurdles of doing developmental approach research. She has many publications and we have discussed them in past episodes. I asked if a randomized controlled trial (RCT) is appropriate for quantifying development that has so many variables that impact it. There’s so much brain research from people like Dr. Elizabeth Torres, we know about brain plasticity, and the question of what we are measuring. A lot of ABA research measures skills. Are we just measuring compliance, though? How is developmental progress defined? 

When my son was very young and I asked for the purpose behind some of the behavioural practices the answer was always about making him “school ready” which I was not worried about at age 2! Even the team at York University had told me he’s a kinesthetic learner. How do we define school success or well-being? So what are we measuring, how often, for what duration, for what purpose (funding? parent support? child support?), and for whose benefit?

I asked Amanda how she organizes all of this when doing publications. Amanda says that RCTs are still considered gold standard for access to funding, at least in Canada. RCTs are making the difference between programs that are offered versus not offered, she continues. This is very challenging, she explains, because when you cluster a group of children who have very different profiles across different age groups and they’re being offered services which are integrated with different services using different techniques and support strategies, it’s really hard to peel apart and discern what is working for one child over another. They’re all lumped together.

What is happening now with RCTs, Amanda shares, is that they’re looking more towards “moderators” and “mediators.” It’s needed, even if not perfect. It’s about figuring out what’s working for who and what it is that is mediating that, i.e., what it is that is making the difference. Is it that the child is receiving a certain number of hours of a program? Is it that they’re receiving a certain number of hours plus OT support plus SLP support that focuses on something specific? This is the hard part, Amanda laments.

Especially with DIR®, Amanda continues, the clinicians who are delivering it really need to tap into their adaptive expertise, and tapping into that also makes it harder because the child might be receiving specific aspects of an intervention, but it is tailored to each individual child and each individual family. So when you’re trying to look at that, RCTs aren’t necessarily the best design for capturing the nuance, and the process that goes into it.

Amanda suggests that you could even do multiple case studies where you’d be able to pick out patterns. Once you have some evidence that’s indicative of different patterns that might be fitting of certain profile–or different combinations of support strategies that are being integrated into programs, then you can also take that information and apply it to some of the RCTs that are being done.

This, Amanda suggests, would allow the mediators and moderators that are being tested within the RCTs to be informed by evidence because while you could choose what to look at to see whether or not it mediates something like number of hours for services, for instance, you are still not tapping into the nuance of the type of program that the child is receiving.

I added that this is really hard to do when you also have to factor in where a child spends the most hours of their day and who they are most connected with. It’s hard to do.

Leaning Into Development

Tracy says that we do have a really strong foundation of research and we need to consider what is it that we’re trying to accomplish and think about key concepts from this approach. She believes that it’s critically important that we trust the DIR® model and that we lean into the core bones of it. This means that when you start to do research that looks at a lot of the nuances and the parts of this intervention that are the strongest, including the parts that are essential across different disciplines, this has to come from a place of understanding the foundation.

The point of research, Tracy continues, isn’t to really just keep reaffirming that what we already know; it’s really to expand what we know. If along that journey of expansion we learn something about some core principle that needs to have a redefinition or a refinement, that’s welcome. She also points out that in the science that has been published, especially in the ABA industry, a lot of it has been just to prove that one thing works over and over and over again without ever understanding what the core principles are.

If you look at the core principles of ABA, Tracy offers, some of them are quite deeply offensive to what we think children and humans need. Additionally, if you just prove a skill changes in a few weeks or a few months, the long-term outcomes of that practice actually don’t hold up and part of that is that a core contrast and a core approach that we take when we adopt a DIRFloortime® approach where we lean into development, Tracy explains.

We’re really trying to understand development, Tracy states, and we’re trying to understand long-term adaptive capacity. If we can shift capacity in the way that somebody understands and makes meaning in the world, understands who they are and the agency that they have as a mover and a doer and a player and a participant, then those changes really do become lifelong. They aren’t just situational and they aren’t short-term changes, she insists.

What Are We Measuring?

Tracy states that the science of development is so fascinating, and it really is the thing that is the key to understanding any of this work. She adds that knowledge can be developed either through gold-standard methods, such as randomized controlled trials (RCTs), or through practice-based evidence generated in everyday clinical work, when clinicians carefully document what they are doing, the questions guiding their work, and recognize that those questions are meaningful and valuable. When we’re not sure what’s happening and need to understand something, we can bring in other disciplines to help strengthen what we’re offering. All of this is welcome, Tracy explains.

Tracy says that we don’t practice from a place of research being defensive, rather, research is expansive. Jeff adds that there’s a saying that says something like just because you can measure something doesn’t mean it is really worth measuring. He questions why many things in the Autism field are measured and wonders why they’re important. The developmental process is much more of an inside out process where we’re trying to understand what’s happening underneath the surface that we’re seeing, but these things are often the hardest to measure, he states. Yet, they’re the most important things to measure.

Jeff continues that that’s part of where we struggle–from a developmental standpoint–with some of the research because it’s easy to measure some behaviors. In addition, a lot of the assessment tools are designed around those behaviors. There’s such an infrastructure in the research world that’s set up to go in that direction of measuring. It’s about what’s observable and easily measured.

Amanda says that it impacts whether or not the publications get published and make their way out to the world for people to access. At the York University DIRFloortime® study, they used two different measures. One of the measures was more of a standardized language assessment, and they also looked at language samples. What the standardized language assessment captured was very different from what a language sample captures. And so they were different results.

They did a scoping review of literature in the field, Amanda continues, to look at the different outcome measures that are used primarily with Autistic individuals, and some of the results are that the outcome measures are more focused on the skills or activities, not participation. But how is this child able to generalize the things that they’re doing within their sessions with clinicians? Are they using that to participate in their education, in their arts programs, or in their day-to-day interactions or play dates with friends? These are actually the things that families say really matter to them, Amanda asserts, and yet, the outcome measures in the field don’t represent that.

Amanda points out that it’s faster and easier to do the standardized language tests and you need funding to be able to go through and translate transcripts from interactions. Looking at the language in a conversation means looking at that interaction, and all of that takes a lot of time. From a research perspective, that funding is a challenge we’re trying to overcome.

The Problem with a “Sensory Profile” Measure

From an occupational therapy perspective, Tracy shares that Temple Grandin had done a lot of advocacy to suggest to the funding resources in the United States (and particularly the federal mechanisms) that whenever a study related to any person that included Autistic individuals was going to be done, that they needed to include a look at development including sensory and motor features, language, and relational features. From that advocacy, there was an internal mechanism that was put in place that future research would include a number of these different areas with funding for studies.

Tracy continues that the sensory profile was adopted in almost every study going forward and although the sensory profile is the tool that is used to identify whether or not there are sensory issues, it really only looks at the features of sensation that we would call sensory modulation and regulation. While these are important parts of sensation, they are not the only parts, and because the sensory profile tool only measures certain things in a certain way, all the rest of “sensory” is left in the dust.

Tracy says that the sensory profile is circumscribed and limited, and really wasn’t designed to help us understand the developmental nature of how sensation is a part of a profile, yes, but more so a part of a developmental unfolding. So it is a question of the mediators and the moderators and really understanding outcome measures. Tracy stresses how important it is, when reading a study, to look at the methodology and really understand what outcome measures were picked and for what reason.

Amanda adds that when looking at caregiver coaching-based programs, she’s noticed that the sensory profile is filled out at the start of a study when families are new to the idea of children having sensory differences, so they might not quite know how to score the test at the onset. By the end of the programs that families are receiving, we hope that they will have a better understanding of sensory differences, but that can mean that the scores in those tests sometimes don’t reflect change but rather the caregivers starting to develop a new understanding of sensory differences and how they impact their child in a particular day.

The Problem with a Measure of “Behaviour”

I shared that Jeff and I both have backgrounds in psychology which makes me consider the psychological experience of the child, and the impact on their self-esteem and their confidence, etc. as well as what the parents are used to from their own backgrounds growing up, and what they’re comfortable or uncomfortable with. I’m also curious about how susceptible to other people’s perceptions parents are since parents are learning about their children in such a behaviorally-driven society that is so outcome-based and sometimes our kids are “behaving” in a way that make people look at you in a negative way. Then, there’s cultural differences in what’s expected of our children.

There’s so many factors that come up, and as a parent, myself, what really stood out to me early on is the occupational therapy component because my son, along with kids of caregivers in the parent support meetings I facilitate, can have a behaviour that looks exactly the same as that of another kid, but so many different things are happening underneath it. And, we’re hearing so much about this divide with mostly non speaking kids with very high support needs that have a lot of things going on in their body that are preventing them from controlling their body, and communicating in ways that other people understand that makes some believe they have an intellectual deficit, even when they don’t.

A non speaking child might be able to show one thing that another child can’t on one day, but then can a day later because they had a better night of sleep, for instance. For my son, there’s so many things going on that could have been invisible. For example, he can read signs when I’m driving better than I can with my prescription glasses, yet he has astigmatism and an odd glasses prescription that is probably impacting his peripheral vision and other things that impact his visual spatial capacity and coordination and whether or not he can do certain tasks. So, there’s something going on with his eyes that you would never have caught if you didn’t go to the developmental optometrist, for instance.

Then there’s the other body systems including gastrointestinal (GI) issues that so many Autistic kids have. We’ll notice aggressive behavior a half hour to 10 minutes before a bowel movement, but if you don’t have that interceptive sense yet to say that you feel something happening in your stomach and think you have to go to the washroom, it might come out as aggression. Then, the bowel movement comes and the child is as happy as can be.

So, depending on the time when you measure behaviours, different factors come up, and you can’t possibly measure every possibility. What’s really clear to me is that there’s something going on in the body for most of our kids that sensory integration can really target, and all of us Floortimers know that it’s the sensory mixed with the affective and with the motor, and how it all has to be through relationship.

Tracy says that what she admires deeply about the DIR® approach is the D, the I, and then the R. She is so grateful to have a framework that we really can lean in to in understanding individual differences in a developmental framework, and then understand the power of relationship to influence all of that. She worked with Dr. Stanley Greenspan one-on-one, and one of the things that Dr. Greenspan brought to all of us, Tracy shares, is that he was a master translator of other science and distilling a lot of information coming from infant mental health and many different lanes.

When the unfolding of development is different and you see some challenge happening in fundamental–especially emotional-developmental capacities, Tracy continues, we should be looking at the sensory, affective, and motor functions in the nervous system and in the brain-body connections. When there are barriers, higher level capacities are impacted and we see the restrictions–not just in emotional development and in relational development, but in communication, in overall coherence, and in making meaning in higher level adaptation, she explains. All of this has to be linked back to the foundational sensory, affective, and motor processes that are also neurological.

Tracy adds that these are brain and body systems that we can learn how to observe, just like we can learn how to observe behavior. We can learn how to observe these foundational components. As we all collectively do that in this community, then we can name the barriers to capacity building. Then we look at how to begin to create those necessary conditions to help alleviate the struggle and promote the developmental unfolding. Tracy concludes that this kind of iterative thinking is really central to the DIR® model and how sensory, affective, and motor features influence individual differences.

Qualitative Components of Research

Coding video interactions in research, like they did in the study at York University in Toronto, can make it more objective, taking into account inter-rater reliability, etc. can add to a simple behavioral outcome of whether a child completed a task or not, I posited. Amanda said it’s important to have that qualitatively understanding of what’s going on in the clinicians’ mind as they’re coaching a caregiver, for example. Understanding what they’re noticing helps with fidelity. If you’re able to document and talk about processes that clinicians go through, you’re then able to teach and train clinicians to think in these different ways, she suggests.

Since DIR® is such like a transdisciplinary profession, you’re looking at child development from many different lenses. As a speech-language pathologist, Amanda was trained in one area and saw a child through the lens of a speech-language pathologist. She is not an occupational therapist nor a mental health therapist, but through working so closely with them and starting to see what they are noticing, it expands your view as a clinician. It then, in turn, helps you to practice in different ways from a research perspective, if we’re able to understand those processes. Amanda concludes that this is something that can help us move things forward in the field.

Amanda adds that the mediators and moderators are important as well, and we want to understand the various factors such as bowel movements and sleep, but you won’t have a study that is powered well enough to be able to look at all of those different things, but documenting these things is one step we can take to move things forward.

Understanding the Whole Process

Jeff says that the beauty of DIR® to him is that it really captures the whole person. There’s so much that is included in DIR® and how the whole person develops rather than the different categories. There’s so many tests and ways we look at the categories of development, including attachment, how it’s happening, and what impact that has, and cognitive or physical, etc. It requires a transdisciplinary approach. It’s actually one of the challenges in a leadership role. People want a Floortime certified practitioner, which is like its own profession like how ABA has the BCBA, but in so many ways, Jeff worries that that undermines the transdisciplinary nature.

Jeff noticed that the word, “understanding” has come up a few times and in this practice, we promote the parent truly understanding their kid and understanding more than just what the behavior is saying. In regards to bowel movements as the behaviour and that reaction that Daria mentioned, having that understanding of it just changes everything and for the child, Jeff insists. The child feeling understood is huge.

Jeff wishes there was a way that we could measure that understanding of the clinician really understanding the parent really understanding the child, or the individual being supported–knowing they’re being understood and what impact that has. It has a rippling effect that impacts the process, yet we don’t really measure that. In fact, Jeff adds, there’s some efficacy studies about parent self-efficacy, based on understanding what’s going on with their child.

The Impact of Research on Training

If we’re thinking about services being funded, and they’re only funded because there’s research behind them, we have the majority of people delivering services to Autistic children who have very little training. They’re right out of school. Usually, there’s a very high turnover. They’re very young, and they’re very eager to help. But what they’re learning might be a methodology that’s based on something that doesn’t even impact whether you understand what the child’s going through.

I find that it’s people that are very intuitive and good with kids that are best rather than any particular methodology, and I think that’s where we need to change it going forward. If all that we discussed in this episode can be validated in the literature, training models could be improved, embodying that clinician understanding over “strategies” and really understanding how the child is experiencing the world, looking at the DIR® thinking like the “why” behind behavior and being curious. All of this costs money, though.

Anyone would love to have our child get occupational therapy services from the top OT, speech-language services from the top SLP, and counseling from the top mental health professional, but it’s just not feasible because the majority of people providing these services are not that trained yet. I continued that that’s the value of the research: to drive the curriculum and impact services going forward.

Listening to Parents

Tracy shares that in the clinic she founded in Denver, several 100 kids come through to see different clinicians each week and many may have been involved in other kinds of services before, whether they were developmental in nature or behavioural in nature, or a variety of things. One of the places to access information is actually from parents who’ve noticed a shift in their services when they start to access relationship-based, developmentally-informed interventions, she suggests.

It is a very strong and clear message, Tracy continues. The discrepancy between what parents are reporting and what other professionals are reporting is actually something to be paying more attention, she adds. For a long time parent voices were minimized. This month in the Journal of Autism, there was an article discussing the big discrepancies between parents reporting adaptive outcomes and teachers reporting adaptive outcomes and part of that is because teachers want kids to perform and participate in school and school is a microcosm of life. But, it’s not all of life, and parents are experiencing children for more than at school, Tracy shares.

As we share developmental frameworks that are more holistic and help people to understand and advocate for that, it does create a ripple effect, Tracy insists. It does matter.

Transformative Approaches to Education

Amanda shares that similar to how professions tend to work in silos, research also tends to work in silos. In collaborations with education science researchers, she’s been learning that there is a lot of work that has been done in medical education for looking at how to promote cross-pollination across professions and also how to teach in different ways for different outcomes. We can look at transformative approaches to education and how those transformative approaches can start to broaden the perspective. It is another thing that can help to move this work forward, she says.

For instance, through coaching, if we’re doing parent-mediated approaches, Amanda states, we are educators as well as clinicians in that role. And so many of the programs like the traditional training programs don’t necessarily focus on that education piece, Amanda continues. But if you can start to integrate that in, things will move forward more quickly and hopefully start to expand.

“Promoting Development” over “Intervention”

I added a disclaimer that it’s very important to stress that when I’m thinking about intervention, I’m thinking about real struggles that my child has that can really be remediated through sensory integration occupational therapy in a relational sense. Autistic children do not need interventions to not make them “look autistic.” People’s minds work differently. The “I” in DIR® encompasses all of these individual differences. And that intervention piece is where we go in and we help bring out someone’s potential overcoming the challenges that someone has the ability to help them through their trained profession versus needing to fix someone.

Jeff adds that part of what he really appreciates about Floortime is that it’s about growth and development and learning in anyone, yet, what we measure in research is the intervention that’s being utilized to address some sort of diagnosis or some sort of defined challenge. We can almost lose focus on what Floortime really is about when we’re putting it into research because we have to show that it can work instead of thinking about it as promoting development, regardless of what developmental pathway that individual is on. It’s hard to get research on that because it’s not directly connected to money or services.

And we don’t want to impose things on Autistic kids that are not ethical, I added. So, once a child is old enough, and they understand that they want to feel regulated and comfortable in their body, they decide to see their occupational therapist because they get that support.

Concluding Thoughts

Tracy: The more we can help people understand that learning DIR® and becoming a Floortime practitioner is a game changer. It really elevates your practice. It helps you to better address the needs. And then the more folks that we have doing it, the more compare-contrast opportunities we have to sample, and the stronger the research base.

Amanda: I’m excited about kind of where things are moving next with the work and already have some ideas brewing for studies moving forward.

Jeff: In so many ways, I’m thrilled with where we are at, in regards to DIR® and research. There is so much out there that was not there 15 years ago, even though the practice and the theoretical framework is decades-old. And there’s so much out there to support what we do within DIR®, and what we do in regards to the practice of Floortime. At the same time, there are gaps and we need more research. The more that that grows, that will expand access for families to get Floortime and funding to support Floortime.

With that said, when I’ve seen the right people in front of the right funders, explaining the research, typically, you can make a really strong case on the current research that exists so far. There’s a lot out there and a lot to hang our hat on that this approach works, but the reality is, we need to keep to expanding. We need to keep looking deeper at things we’ve looked at before to continue to grow in the context of the science we know now, and hopefully that will continue to happen.

A big “thank you” to this episode’s guests for agreeing to participate on the DIR® Dialogues panel and I hope that you found it a worthwhile listen. If so, please consider sharing it on social media!

Until next time, here’s to choosing play and experiencing joy every day!

Thank you to Athan Maroulis and Metropolis Records for the intro/outro song permission.