Pediatric PT & OT Services – Seattle, WA Pediatric Therapy

DIR®/Floortime is the developmentally appropriate, relationship-based approach to treatment developed by Stanley Greenspan, MD and Serena Wieder, PhD.  It is a comprehensive treatment model that addresses the individual differences of the child.  The goal of the DIR®/Floortime program is to develop a continuous flow of interaction with a child throughout their day.  Initially, this is developed in the focused interactions of the sessions but then expands to all the incidental interactions that continually occur throughout the day.
The DIR®/Floortime model includes the “D” which is the six core capacities of Functional Emotional Development, the “I” which is the individual differences of the child, and the “R” which is relationships that are the vehicle for creating learning interactions.

Understanding a child’s individual differences including their sensory reactivity and regulation is essential for all who work with children on interactions and learning. These individual differences including the sensory modulation continuum of sensory registration and response to stimuli influences behavior, attention, impulse control, praxis (motor planning and sequencing), auditory/verbal  and visual processing as well as the child’s interaction with people and objects, and how they develop ideas.

The DIR®/Floortime Model is an effective treatment approach that can be used with children with disorders in communicating and relating including children diagnosed with Autistic Spectrum Disorder.  Using this model, parents learn strategies that increase the child’s attention to task and affective interaction. The goal is to enhance the dance of social interaction, to recognize when and how “affect” is the most appropriate strategy to engage a child. Parents will recognize the child’s “comfort zone” in play and be able to know when and how to use sensory and physical activity, and language to engage the child and help them problem solve and elaborate ideas.

The core capacities for functional and emotional development that Greenspan describes occur in the flow of parent/infant interaction in the first four years of life.  As core capacities develop they enable the child to become calm, regulated and attentive, to develop warmth, intimacy, the ability to develop relationships and to function as a member of society.

The six levels of development include:

  1. Attention and Regulation
  2. Forming Relationships and Mutual Engagement
  3. Intentional Two-Way Communication with Gestures
  4. Two way Purposeful Interactions with Complex Gestures and Problem Solving
  5. Elaborating Ideas, Pretend Play, Creating Symbols
  6. Building Bridges Between Ideas, Emotional Thinking, Connecting Symbols, Logically and Abstract Thinking

“Attention and Regulation” In the first few months of life the parent is helping the infant calmly regulate themselves while they become interested and take pleasure in the sights, sounds, tastes, and touches that the parent offers.  This ability will help them organize their senses and motor responses and create a deep sense of security.

“Forming Relationships and Mutual Engagement” During the second stage of development, when they are between three and six months of age, the baby grows in their ability to engage in an intimate relationship with the parent.  They’ll experience more and more warmth and pleasure and all the related other feelings that spring out of engagement with the parent. This is the time that the infant “woos” the parent and the parent falls in love with the infant.  The infant also seeks interaction with the parent for comfort and soothing when needed, so that they can deal with satisfactions and frustrations.  As the child grows, the capacity for engagement will embrace the full range of emotions (joy, caring, anger, jealousy, fears, competition etc.), supported by affect cues (e.g. smiles or scowls) from others. Mutual engagement helps the child stay engaged and feel comfortable and curious about different experiences.

“Intentional Two Way Communication with Gestures” By the time the child is about nine months old they exchange gestures in a purposeful way.  With parental support, reading and responding to their cues, they will eventually be able to string together more and more of these emotional expressions, sounds and actions.  This is the beginning of the child conveying their intensions or desires to start the “conversations” needed to participate actively in the world.  The simple gestures of a child less than a year old, such as pointing or playing “give and take”, turn to complex gestures in the second year, and then to back and forth conversation as the child develops language. The parent’s response such as making a funny face, or tempting actions, such as covering their favorite rattle with a hand, will inspire them to master the baby version of logic or two-way communication far better than any educational toy or picture book.

“Two Way Purposeful Interactions with Complex Gestures and Problem Solving” – By the time that the child is a year to a year and a half, the child will be learning to be a “complex social problem solver”.  They will take you by the hand to get you to help them. They are starting to figure out how the world works and may even vocalize their own version of words, along with a few real ones, to help you understand their intensions.  Complex gestures involve sequences – all the steps needed to communicate and solve problems – first through actions and then with words as well. When the child grabs their parent’s hand and points to the cupboard to get a toy they want, they are making their first attempt at social problem solving. As the parent nods back, the child motions until the parent hoists them up in their arms and they can grab the toy.  The child is not only delighted and proud, but they will also be on their way to becoming a budding scientist. The toddler learns that problems get solved through many interrelated steps, and that the world, including their physical surroundings and their own personality and that of their parent, is made up of patterns.  No colorful pop-up toy or computerized light and sound gadget can come close to matching the companionable lessons in problem solving that a parent can offer their child as they play and engaged in gestural dialogues together.

“Elaborating Ideas, Pretend Play, Creating Symbols” By the time the child is 24 to 30 months the child is displaying a new ability that is nothing short of miraculous. They will be capable of creating richly detailed, multisensory pictures that we commonly refer to as symbols, or ideas. The child and parent share the development of the child’s use of ideas and creativity.  Now instead of just acting on their environment to get their needs met, they can form mental images of their wants and desires, and label it with specific spoken words.  Instead of plucking your sleeve, dragging you over to the cupboard, pointing to the bag of cookies and jumping up and down in anticipation, they’ll look you in the eye and demand, ‘Cookie now!”. The parent and the child share the development of the child’s use of ideas and creativity. This occurs as the child and the parent begin to expand play as they pretend to be “a cat and a dog,” “a king and a queen,” or “have a tea party”. The child begins to express thoughts, ideas, and feelings through symbols, using pretend play and words.  A child can communicate what they imagine through role play, dress up, dolls, action figures, which now represent experiences from real life as well as those learned from other sources.  These become their own as they project their feelings into the character and actions. Play emerges as the child’s choosing rather than from set games or impersonal manipulative or computerized toys.

“Building Bridges Between Ideas, Emotional Thinking, Connecting Symbols Logically and Abstract Thinking” – Between 36 and 48 months the child begins to develop logical bridges between ideas, or analytical thinking.  It emerges from more elaborate pretend play, as well as from debates over bedtime or cookies, and from those around them asking them their opinions. Questions such as “Why do you want to go outside?”, “to the park?”, or “to grandma’s?”, rather than rote teaching of letters or numbers teaches the child to connect their ideas and be a logical thinker. As the child begins to build bridges between ideas their play has a logical beginning, middle and end, taking time and space into account. Realistic conversations and pretend play stories are now made up of logically interconnected ideas, with clear motives and anticipated consequences. The child can now also abstract and reflect on various feelings and lessons to be learned.

Typically each core capacity continues to develop as the child matures, supporting the next level.  However, some children may show some capacities in a constricted form at a higher level even if they have not fully achieved more basic levels.

The DIR®/Floortime Approach is a highly effective treatment approach that focuses on the interactive process with the child. There is an emphasis on the interaction between the child and the parent/caregiver, with the goal being directed toward developing attention and regulation, mutual engagement, purposeful interaction with gestures and problem solving, elaboration of ideas and building bridges between ideas.  The DIR®/Floortime approach is appropriate for children who have difficulties in all or some of these areas of development; it is also wonderful as a philosophy of interaction with all children. This approach recognizes that a child’s functional emotional capacities and individual differences influence development through the medium of the child-caregiver relationship. The child brings their individual differences into the interaction patterns in order to negotiate and hopefully master each of the core functional developmental capacities.