Recent Research on Intensive Developmental Interventions (IDI) for Young Children with Autism – Dr. Rick Solomon, MD

Intensive developmental interventions (IDI) are consistent with the National Research Council (Lord et al, 2001) recommendations for ‘intensity’ (25 hours/week, high adult to child ratio, highly engaging, and strategic in goals). While individual IDI programs may differ in some methodologic details, they all address children’s individual abilities and strengthen the parent-child relationship (Kasari, 2008; Kasari, 2010). IDI programs research outcomes focus on joint attention, social engagement and reciprocity, and symbolic play—core deficits in ASD.

IDI is evidence based. Research methods range from the less rigorous large case series Greenspan, 2001) and pre/post design (Solomon, 2007) to the more rigorous approaches including single subject, multiple baseline designs (Ingersoll et al, 2005), controlled trials Mahoney & Perales, 2005; Jocelyn et al, 1998, Pajareya, 2011) ), and randomized controlled designs (Aldred, et al, 2004; Green et al, 2010, Casenheiser, 2011). 

Each study used video measures to show that parent-child interaction can indeed be measured live.  While these research approaches are more difficult to operationalize and quantify compared to behavioral approaches (Dawson & Galpert, 1990; Rogers, 2000; Siller & Sigman, 2002), scientific support for them is steadily growing.

Taken together the studies provide solid evidence that parents can learn the interactional methods necessary to improve interactional abilities and functional development in children with autism.  

As more rigorous evidence accumulates, IDI will offer a distinct alternative to the ABA/EIBI approaches for parents, school districts and states. Behavioral, skill-based methods improve IQ in children with ASD older than 3 years of age while developmental, play-based methods improve parent-child interactions and functional development and are especially valuable for children younger than 3 years of age. Perhaps, in the future, skill-based and play-based models may end up being combined (Rogers, 2000) to create best practice. Autism is a diverse condition and ‘one size does not fit all’ children or families. ABA is not a panacea. A recently published systematic review and meta-analysis of the efficacy of Applied Behavioral Intervention (ABI) in preschool children concluded that there is inadequate evidence that ABI has better outcomes than standard care for children with Autism (Spreckley et al, 2009).

The meta-analysis included only the studies that have the most rigorous scientific design (Eikeseth et al. 2002, 2007), Smith (2000), and Sallows (2005). The sample size of all these studies is small (23-28 children, including the control group) and target children ages 33 months and older. Two additional systematic reviews of psychosocial interventions for autism (Krebs Seida et al, 2009; Ospina et al, 2008) conclude that the available studies are methodologically weak and this precludes definitive conclusions regarding their efficacy. Actuarial cost studies for several states (Georgia, Missouri, Kansas, Virginia, and Washington) have estimated that average ABA programs will cost between $30,000 and $60,000 per year (Wyman, 2009a, b, c, d, e). In summary, there is limited and inconsistence evidence of ABA efficacy for children 33 months and older, and lack of evidence for younger children. Alternatives to ABI must be considered especially approaches that are cost effective and fit within the context of families’ lives.

IDI methods are especially parent friendly and work well in the natural environment of the home. While methodologically rigorous research on parent training interventions is scant (Drew et al, 2002) several studies using developmental methods have been shown to be effective in training parents. Mahoney & Perales’ (2005) Responsive Teaching approach, The PLAY Project Model (Solomon et al, 2007) and The PACT Study (Aldred et al, 2004; Green et al, 2010) each used parent training as a cornerstone of their approaches with positive results. Again, another distinguishing benefit of developmental methods is their special appropriateness for very young children. The youngest age of diagnosis for children with autism has recently been revised downward to 14 months (Landa, 2006). Developmental approaches offer many options for children this young.

The above research is the foundation from which future research is being built. Indeed, Mahoney (http://www.crainscleveland.com/article/20090925/FREE/909259974/1007), Solomon (http://www.playproject.org/eventsandnews_news.php) and Weatherby and Prizant (http://www.scerts.com/research-corner) have all recently received large awards to rigorously replicate and expand on their earlier work.

In summary, ASDs are increasingly being identified in young children. The National Academy of Sciences recommends comprehensive, intensive interventions. Despite the number of both behavioral and play-based models being offered nationally to families, services are not readily available publicly or privately. Expense, problems with training of skilled personnel, difficulty replicating rigorous model programs and poor delivery systems have limited broad dissemination of services in most states. The various types of intensive developmental interventions (IDI) are emerging as legitimate evidence based options for parents of young children with autism.


The PLAY Project Home Consultation Intervention Program for Young Children with Autism Spectrum Disorders: A Randomized Controlled Trial

Importance The number of children diagnosed with autism spectrum disorders (ASD) is increasing. In most states, behavioral intervention services as delivered by professionals are expensive, difficult to implement, and there are shortages of trained personnel. Many young children with ASD are not receiving needed services. Parent-mediated models are much less costly, easily disseminated and, if shown to be effective, could address a national need.

Objective To evaluate whether the PLAY Project Home Consultation (PLAY) parent-mediated model is effective in improving social impairment and reducing autism severity in young children with ASD.

Design, Setting, and Participants Children (N=112), 3-5 years old, diagnosed with ASD were randomly assigned by age, gender, and severity to a community standard (CS) intervention (special education pre-school, language and occupational therapy) plus PLAY versus a CS intervention only in four U.S. sites in two one-year cohorts.

Intervention PLAY is a manualized, once a month, home visiting program that uses videotape and written feedback within a developmental, relationship-based framework to promote intensive, parent-mediated intervention for young children with ASD. The model has been disseminated in 27 states.

Main Outcome Measures Primary outcomes were: (a) parent interactional ability; (b) child social interaction, language, and development and (c) child autism severity. Secondary outcomes were a.) impact of intervention on parental stress and depression and b.) PLAY consultant fidelity to the model.

Results PLAY children were twice as likely as CS children to improve in diagnostic category on the Autism Diagnostic Observation Scale (odds ratio = 2.41). Large treatment effects were evident for improvements in parent and child interactional abilities on the Maternal and Child Behavior Rating Scales. Child language and cognitive outcomes, however, did not differ over time by treatment group. PLAY participation did not increase parent stress and depressive symptomatology decreased after intervention. Home Consultants administered PLAY with fidelity.

Conclusions and Relevance This is the first randomized controlled trial of a parent-mediated training model to demonstrate a reduction of autism severity in young children with ASD. PLAY is relatively inexpensive, easily disseminated, and has the potential to serve underserved populations.


Evidence Base for the DIRFloortime® Approach - Diane Cullinane, M.D., 11-2014

DIRFloortime is a way of relating to a child in which we recognize and respect the emotional experience of the child, shown in their actions, ideas, and intentions, and interact in a way that helps the child to achieve a greater sense of purpose, building their capacity to engage and communicate at increasingly complex levels of functional development.

DIRFloortime is derived from over 50 years of study and research about child development from the fields of psychology, medicine, and education, and includes the areas of language, attention, mental health, infant development, sensory processing, and motor development. 

“Evidence-based practice” means a decision making process which integrates the best available scientifically rigorous research, clinical expertise, and individual’s characteristics. Evidence-based practice is an approach to treatment rather than a specific treatment. Evidence-based practice promotes the collection, interpretation, integration, and continuous evaluation of valid, important, and applicable individual- or family-reported, clinically-observed, and research-supported evidence. The best available evidence, matched to infant or toddler circumstances and preferences, is applied to ensure the quality of clinical judgments and facilitates the most cost-effective care. [CA Trailer Bill 2009]


What to measure?

A starting point to measure effectiveness of intervention is to determine the factors to be measured.  This is a major challenge in the field of developmental disabilities.  Generally, behavioral approaches measure specific targeted behaviors. More recently, there has been a focus on measuring spontaneous interactions and generalization of skills, which presents new challenges in measurement. In contrast, developmental programs target underlying capacities, or ‘core deficits’ as the focus of intervention, with progress evident in a complex array of changes in interactive behavioral patterns.

Developmental approaches seek to measure changes in an individual’s capacity for:

  • Shared attention
  • Ability to form warm intimate and trusting relationships
  • The ability to initiate(rather than respond) using intentful actions and social engagement; spontaneous communication
  • The ability to participate in reciprocal (two-way, mutual) interactions while in a range of different emotional states
  • Problem solving through a process of co-regulation, reading, responding and adapting to the feelings of others
  • Creativity
  • Thinking logically about motivations and perspective of others
  • Developing an internal personal set of values

These developmental measures are more closely aligned to the diagnostic criteria for autism spectrum disorder than those often used in older research such as IQ, performance on early academic skills and responsive behaviors.  The National Research Council stated in 2001: “More appropriate outcome measures are improvement in initiation of spontaneous communication in functional activities, and generalization of language across activities people, and settings”

Lord, Catherine; McGee, James (Editors). Committee on Educational Interventions for Children with Autism.  Educating Children with Autism.  Division of Behavioral and Social Sciences and Education, National Research Council.  Washington, DC:  National Academy Press (2001) p 217

An additional challenge confronting all researchers in the field is the wide diversity of individuals with a diagnosis of autism or a related disorder.

Warren, Z. et. al. in “A Systematic Review of Early Intensive Intervention for Autism Spectrum Disorders” stress the need for further research “to better characterize subgroups of children who respond differently to individual approaches” and conclude that “There is not yet adequate evidence to pin-point specific behavioral intervention approaches that are the most effective for individual children with ASDs.”

Warren, Z. et al, Pediatrics, Vol 127 No5 May 2011

Developmental models emphasize individual differences and the need to tailor intervention to the unique biological profile of the child and to the unique characteristics of the parent-child interaction.  

Research is challenging both because both the factors being measured are complex and because of the wide range of individual differences in the population.  In considering the evidence for DIR/Floortime, it is important to appreciate the challenges to studying a complex model, and to consider the long history of study on the effectiveness of various facets of a developmental framework.  These can be summarized by looking at the three major aspects of the DIR/Floortime approach:  “D”- developmental framework, “I”- individual differences, and “R”-relationship and affective interactions.  

While randomized controlled trials are held as the gold standard, because of the wide range of individual differences in autism, there is more interest in using single-subject research design.

A single subject study design was used to evaluate the effectiveness of Floor Time Play with a 3.6 year old boy with autism.  The study used an observation and intervention phase, and utilized circles of communication as the measure of change. Results showed a significant improvement using Floor Time play strategies, and mother’s journal included insights on the changes observed.

Dionne and Martini, Revue canadienne d’ergotherapie; June 2011 78 (3) 


“D” Developmental

A developmental approach is founded on work by major developmental theorists such as Piaget, Vygotsky, Erikson, and Kohlberg.  A developmental approach considers behavior and learning in the greater context of a developmental or changing process.  DIR theory was first described by Dr. Greenspan in 1975 and was further developed over the next 20 years.  He received high honors and acclaim for his work including American Psychiatric Association's highest award for child psychiatry research.

Greenspan, S.I, A Consideration of Some Learning Variables in the Context of Psychoanalytic Theory, (1975)
Greenspan, S.I. Intelligence and Adaptation, (1979)
Greenspan, S.I. Psychopathology and Adaptation in Infancy and Early Childhood (1981)
Greenspan, S.I. First Feelings (1985),
Greenspan, S.I. The Essential Partnership (1989)
Greenspan, S.I. The Development of the Ego (1989)
Greenspan, S.I. Infancy and Early Childhood (1992)

In 1997, Dr. Greenspan and Serena Weider published, The Child with Special Needs: Encouraging Intellectual and Emotional Growth and in 2006 they published, Engaging Autism.

In 1997, they reported the results of an extensive chart review of 200 children with autism who had received DIRFloortime.  This showed the promise of the DIR/FT approach:

The goal of the review was to reveal patterns in presenting symptoms, underlying processing difficulties, early development and response to intervention in order to generate hypotheses for future studies. The chart review suggests that a number of children with autistic spectrum diagnoses are, with an appropriate intervention program, capable of empathy, affective reciprocity, creative thinking, and healthy peer relationships; that an intervention approach that focuses on individual differences, developmental level, and affective interaction may be especially promising;

Greenspan, S.I. and Wieder, S. (1997) Developmental patterns and outcomes in infants and children with disorders in relating and communicating: A chart review of 200 cases of children with autistic spectrum diagnoses. Journal of Developmental and Learning Disorders 1:87-141.

8 years later, they reported the follow-up of a subgroup of children, showing that it is possible for children with autism to become empathetic, creative, and reflective thinkers.

Greenspan, S.I. and Wieder, S. (2005) Can Children with Autism Master the Core Deficits and Become Empathetic, Creative and Reflective? A Ten to Fifteen Year Follow-up of a Subgroup of Children with Autism Spectrum Disorders (ASD) Who Received a Comprehensive Developmental, Individual-Difference, Relationship-Based (DIR) Approach. The Journal of Developmental and Learning Disorders 9.

Previous approaches using behavioral principles relied upon outside motivators on the premise that children with autism did not have their own motivation to participate in social interaction or to learn.  The DIR/Floortime approach revealed that all children will show purpose and initiative, and will seek close social relationships when provided with interactions which respect their interests and are tailored to their individual differences.

The DIR/Floortime approach has provided a developmental framework that has been studied and found to be accurate and effective in understanding behavior.  The widely used Bayley Scales of Infant development has adopted the DIR milestones as the measure of social-emotional development through a process of careful standardization across populations. 

The following research studies report the effectiveness of developmental approach: 

20 authors, representing 17 major institutions, and 3 countries collaborated to write a paper which outlines principles of assessment and effective intervention for children with suspected autism under the age of 2. They concluded “Interventions should ultimately be directed toward specific functional concerns and be informed by key developmental principles, including the child’s role as an active learner, the social contexts of learning, and the pivotal role of the parent-child relationship.”  These principles are basic tenants of the DIR/Floortime approach.
Zwaigenbaum et al (2009), Clinical Assessment and Management of Toddlers with Suspected autism spectrum disorder: Insights from studies of High-risk infants.

In 2010, Wallace and Rogers published a review of controlled studies which identified four factors which were most important for effective intervention for infants with autism. These were: “(1) parent involvement in intervention, including ongoing parent coaching that focused both on parental responsivity and sensitivity to child cues and on teaching families to provide the infant interventions, (2) individualization to each infant’s developmental profile, (3) focusing on a broad rather than a narrow range of learning targets, and (4) temporal characteristics involving beginning as early as the risk is detected and providing greater intensity and duration of the intervention.”

Wallace Katherine S. and Rogers Sally J. Intervening in infancy: implications for autism spectrum disorders Journal of Child Psychology and Psychiatry (2010)

More and more, intervention models are incorporating these elements, which are all fundamental features of the DIR/Floortime approach including:

Rogers, S. and D. Delalla. (1991). “A comparative study of the effects of a developmentally based instructional model on young children with autism and young children with other disorders of behavior and development.” Topics in Early Childhood Special Education 11: 29-47.

Jocelyn, L., et al. (1998). Treatment of children with autism: a randomized controlled trial to evaluate a caregiver based intervention program in community day-care centers. Developmental and Behavioral Pediatrics, 19, 326-334.

National Research Council and Institute of Medicine (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development. Jack P. Shonkoff and Deborah A. Phillips, eds. Board on Children, Youth, and Families, Commission on behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

B. Hwang & C. Hughes (2000) “Increasing Early Social Communicative Skills of Preverbal Children with Autism through Social Interactive Training.” Journal of the Association for Persons with Severe Handicaps, Vol 25, pp. 18-28.

Salt 2002  The Scottish Centre for Autism preschool treatment programme The National Autistic Society Vol 6 (1) 33
A developmentally based early intervention programme; treatment group showed significant improvement in joint attention, social interaction, imitation, daily living skills, motor skills and an adaptive behaviour composite.

Aldred, C., Green, J., Adams, C. (2004) A new social communication intervention for children with autism: pilot randomized controlled treatment study suggesting effectiveness, Journal of Child Psychology & Psychiatry and Allied Disciplines, 45(8): 1420-30 RCT pilot study, dyadic social communication treatment.  The active treatment group showed significant improvement on ADOS total score, social interaction, language, parent-child interaction.
Vismara, Colombi, & Rogers. (2009). Can one hour per week of therapy lead to lasting changes in young children with autism?  Autism, Vol 13 (1), 93-115

In 2007, Solomon reported a pilot study on the Play Project which showed significant increases in child subscale scores on the FEAS after an 8-12 month program using Floortime.

Solomon, R., J.  Necheles, C. Ferch, and D. Bruckman. “Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation program.”  Autism 11, no. 3 (2007) 205-224. 

In 2014, Solomon et al. reported their findings on a large randomized controlled trial conducted with 128 children with autism, that used a manualized, parent-mediated intervention program called the PLAY Project, which is based on the DIR/Floortime approach.  Parents showed marked improvement in the ability to read their child’s cues, follow their child’s lead, and obtain reciprocal social exchanges. Children showed marked improvement in engagement and initiation and functional development.

Solomon R, Van Egeren L, Mahoney G, Quon-Huber M, Zimmerman P. (2014) PLAY Project Home Consultation Intervention Program for Young Children with Autism Spectrum Disorders: A Randomized Controlled Trial. J Dev Beh Pediatrics. 35(8): 475-485.

In June 2011,  Pajareya published a pilot RCT of DIR/Floortime with preschool children with ASD. Results showed improvements in FEAS, CARS, and the functional emotional questionnaires, confirming the results of the Solomon 2007 study.

Pajareya and Nopmaneejumruslers, Autism, Vol 15(2) 1-15. June 2011.

In a randomized controlled trial, Casenhiser et al. (2011) presented the results of a DIR/Floortime based, social-communication intervention.   A significant association was found between improvements in caregiver behaviors and improvements in children’s social-communicative measures. Results indicate that the treatment group showed significantly greater enjoyment in interactions with their parents, were significantly more attentive and involved in interactions with their parents, and initiated more joint attention.  Initiation of joint attention and involvement were predictive of increase in language skills.

Casenhiser, D (2011) Learning through interaction in children with autism: Preliminary data from a social-communication-based intervention Autism Sept 2011

Casenhiser et. al. (2014) reanalyzed their data from their 2011 research, and documented that the children in the treatment group outperformed the community treatment group on measures of language including, number of utterances produced, and various speech act categories such as sharing, commenting, rejecting/protesting, social conventions and responses to comments.

Casenhiser, D, Binns, A., McGill, F., Morderer. O. & Shanker, S. (2014 ePub). Measuring and supporting language function for children with autism: Evidence from a randomized control trial of a social-interaction based therapy.

Elder et. al (2010) demonstrated significant changes in child and parent behaviors as a result of training fathers in following their child’s lead, imitating with animation, commenting on the child’s actions and expectant waiting. There were significant changes in the child’s behaviors, including increase in child initiating, and child’s non-speech vocalizations.

Elder, J.; O’Donaldson, S.; Kairella; J; Valcante, G; Bendixon, R; Ferdig, R; Self, E; Walker, J; Palau, C & Serrano, M. (published online 2010). In-home training for fathers of children with autism: A follow up study evaluation of four individual training. Journal of Child Family Study. 20(3); 263-271.

In 2013, Siller et. al. conducted a randomized, clinical trial with 70 children with ASD, 6 years of age or younger, using Focused Playtime Intervention (FPI).  The intervention was designed to promote responsive parental behaviors in a family-centered intervention. The intervention focused on play, social engagement, and encouraging increasingly complex child communication and play.  Results showed a significant treatment effect on responsive parental behaviors and a conditional effect on children’s expressive language outcomes, showing that children with baseline language skills below 12 months are most likely to benefit from FPI.

Siller, M; Hutman, T & Sigman, M. (2013). A parent-mediated intervention to increase responsive parental behaviors and child communication in children with ASD: A randomized, clinical trial.  Journal of Autism and Developmental Disorders. March. 43(3), 540-550.

In 2014, Liao and colleagues conducted a study on the effects of the DIR/Floortime intervention with eleven children with autism (ages 45-69 months). The mothers were trained in DIR/Floortime during pre-intervention 1:1 counseling sessions and a three-hour lecture. Each parent conducted the intervention for at least 10 hours a week for ten weeks. There were significant improvements in each child’s two-way communication, behavioral organization and problem-solving and daily living skills with medium to large effect sizes.

Liao, S.; Hwang, Y; Chen, Y.; Lee, P.; Chen, S & YiLin. (2014). Home-based DIR/Floortime intervention program for preschoolers with autism spectrum disorders: Preliminary findings. Physical and Occupational Therapy in Pediatrics. Early online: 1-12.

Other studies have shown efficacy in blending developmental and behavioral approaches:

Koegel, R., Koegel, L., and McNerney, E. (2001). Pivotal areas in intervention for autism.  Journal of Clinical Child Psychology, 30, 19-32.
Historically, behavioral approaches have not focused on relationships or individual differences.  Pivotal Response Training or PRT a form of naturalistic behavioral treatment is a form of behavioral intervention that is based on following the child’s interest to increase motivation, and incorporates some developmental principles into a behavioral model.

Dawson (2010) Randomized controlled trial of an intervention for Toddlers with autism: The Early Start Denver Model, Ped:125 (1)
EDSM is based on developmental and applied behavioral analytic principles.   Children in the EDSM group had “significant improvements in IQ, language, adaptive behavior, and autism diagnosis”

Kasari (2010)  Randomized Controlled Caregiver Mediated Joint Engagement Intervention for toddlers with autism. J. Autism Dev Disord

Significant improvements in joint engagement, joint attention, and diversity of functional play acts, with maintenance of these skills 1 year post-intervention; intervention was focused on “the development of play routines in which the adult could follow in on the child’s interests maintain and then expand upon their play activities.” “The approach involved developmental procedures of responsive and facilitative interaction methods as well as aspects of applied behavior analysis.”

Landa, R., Holman, K., O’Neill, A., and Stuart, E. (2011). Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52, (1), 13-21.
Using a supplemental developmental curriculum in a classroom program targeting socially synchronous engagement in toddlers with autism spectrum disorders, a significant treatment effect was found for ‘socially engaged imitation’, This skill was generalized to unfamiliar contexts and maintained through follow-up at six months.

Lawton, K and Kasari, C. (2012). Teacher-implemented joint attention intervention: Pilot randomized controlled study for preschoolers with autism. Journal of Consulting and Clinical Psychology. 80 (4), 687-693.
In an integrated developmental behavioral intervention resulted in increased Initiation and Joint Attention

I - Individual Differences

In the 1970s Jean Ayres pioneered discoveries about innate sensory processing differences.  

Ayres JA. (1979). Sensory Integration and the Child. Western Psychological Services. Los Angeles, CA.

This provided a new way of understanding movement and regulatory behaviors.  In addition this work showed that these biological differences could be influenced and changed by specific therapeutic interventions.  Over the past 40 years, a huge body of research has further described not only biological differences in sensory-motor processing but further differences in emotional-regulatory processing.  

The National Research Council of the National Academy of Sciences, in their 2001 landmark report, “Educating Children with Autism,” called for tailoring the treatment approach to the unique features of the individual child.   

Lord, Catherine; McGee, James (Editors). Committee on Educational Interventions for Children with Autism.  Educating Children with Autism.  Division of Behavioral and Social Sciences and Education, National Research Council.  Washington, DC:  National Academy Press (2001) p 217
 
A (2011) pilot randomized control study showed the effectiveness of sensory integration treatment for children with autism. Results showed improvement in social responsiveness, sensory processing, functional motor skills, and social-emotional factors with a significant decrease in autistic mannerisms.

Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Research Scholars Initiative—Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65, 76–85

DIR/Floortime places great emphasis on tailoring intervention to individual differences, consistent with the knowledge gained from this research.


R - Relationship and Affect

Developmental models have evolved from many years of discovery in the field of infant mental health.  Beginning in the 1950s, there was a new understanding of the importance of parent-infant interaction, known as attachment theory.

Bowlby, J. (1951). Maternal care and mental health. World Health Organization (WHO). Monograph Series, no. 51. Geneva: World Health Organization.  

Ainsworth, M., Bell, S.M., & Stayton, D. (1974). Infant-mother attachment and social development: Socialization as a product of reciprocal responsiveness to signals. In M. Richards, ed., The Integration of the child into a social world. Cambridge: Cambridge University Press.

Stern, D. (1974). Mother and infant at play: The dyadic interaction involving facial, vocal, and gaze behaviors. In M. Lewis and L. Rosenblum, eds., The effect of the infant on its caregiver. New York: John Wiley & Sons, Inc.

Dr. Greenspan and Serena Wieder contributed to the field with their study of the importance of mother-child interactions in high risk infants.

National Center for Clinical Infant Programs (1987). Infants in Multirisk Families. Case Studies in Preventive Intervention. Stanley I. Greenspan, Serena Wieder, Robert A. Nover, Alicia Lieberman, Reginald S. Lourie, Mary E. Robinson, eds. Clinical infant Reports, Number three. International Universities Press

There is abundant research confirming the importance of parent-child interaction and the value of intervention programs focused on supporting parent-child relationships.  This work has become highly sophisticated in research methodologies examining joint attention and emotional attunement.

Mundi, P., Sigman M., Kasari C. (1990). A longitudinal study of joint attention and language development in autistic children. Journal of Autism and developmental Disorders 20:115-128.

Alan Fogel (1993), Developing Through Relationships, The University of Chicago Press. Synopsis available at http://www.press.uchicago.edu/presssite/metadata.epl?mode=synopsis&bookkey=52786

Board on Children, Youth, and Families, From Neurons to Neighborhoods:The Science of Early Childhood Development, Jack B. Shonkoff and Deborah A. Phillips (Eds.), National Academies Press, Washington, DC, 2000, pdf version at www.nap.edu/catalog.php?record_id=9824

Affleck, G., et al. (2001). Promise of relationship-focused early intervention in developmental disabilities.  Journal of Special Education, 16, 413-430.

Mahoney, G. & Perales, F. (2003). Using relationship-focused intervention to enhance the social-emotional functioning of young children with autism spectrum disorders. Topics in Early Childhood Special Education, 23, 74-86.

Mahoney, G., and F. Perales. “Relationship-focused early intervention with children with pervasive developmental disorders and other disabilities: a comparative study.” Journal of Developmental & Behavioral Pediatrics 26, (2004): 77-85.

Kim, J. and Mahoney, G. (2005). The effects of relationship focused intervention on Korean parents and their young children with disabilities. Research in Developmental Disabilities, 26, 117-130.

Gernsbacher  has shown that intervention can change the way parents interact to increase reciprocity and that these changes are correlated with changes in social engagement and in language.

Gernsbacher M.A., (2006). Toward a behavior of reciprocity. Journal of Developmental Processes, 1, 139-152. http://psych.wisc.edu/lang/pdf/gernsbacher_reciprocity.pdf

Kasari et al. 2008 used a randomized, controlled trial looking at joint attention and symbolic play in 58 children with autism.  Results indicate that expressive language gains were greater for treatment groups which used developmental approaches compared with the control group that was based only on behavioral principles. 

Kasari, Connie; Paparella, Tanya; Freeman, Stephanny; Jahromi, Laudan B. “Language outcome in autism: Randomized comparison of joint attention and play interventions.”  Journal of Consulting and Clinical Psychology. Vol 76(1), Feb 2008, 125-137.

Evidence continues to support parent-mediated intervention as effective for the treatment of children with autism. A review of the literature, which included only randomized controlled trials found evidence for positive change in patterns of parent-child interaction, parent synchrony and suggestive of improvement in child language comprehension and reduction in the severity of children’s autism characteristics.

Parent-mediated early intervention for young children with autism spectrum disorders (ASD) ()Review) 2013 The Cochrane Collaboration, Published by John Wiley and Sons, Ltd.

A large review of over one thousand articles, found evidence of effectiveness for “Parent-implemented intervention.”  Studies are documenting the importance of the key relationships in a child’s life as a focus of intervention.

Evidence-Based Practices for Children, Youth, and Young Adults with Autism Spectrum Disorder  Wong, Odom, et al, (2013) Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute Autism Evidence-Based Practice Review Group.

Many recent studies document the correlation between parental interaction style, engagement, shared attention, and language, including:

Siller and Sigman, Modeling Longitudinal Change in the Language Abilities of Children with Autism: Parent Behaviors and Child Characteristics as Predictors of Change. Developmental Psychology 2008 Vol.44, No. 6, 1691-1704.

Bottema-Beutel, et.al., The Role of Supported Joint Engagement and Parent Utterances in Language and Social Communication Development in Children with Autism Spectrum Disorder. Autism Dev Disord (2014) 44:2162-2174.

Patterson, et.al. The association between parental interaction style and children’s joint engagement in families with toddlers with autism. Autism (2014) Vol. 18(5) 511-518

Claims

Sweeping claims have been made about the effectiveness of behavioral approaches, specifically ABA, however, a careful reading of research reveals that evidence of effectiveness is not so definitive.  In 2001, The National Academy of Sciences report concluded that there is some evidence for both developmental approaches and behavioral approaches but no definitive evidence for either. There have been no comparative studies between these two approaches.

Lord, Catherine; McGee, James (Editors). Committee on Educational Interventions for Children with Autism.  Educating Children with Autism.  Division of Behavioral and Social Sciences and Education, National Research Council.  Washington, DC:  National Academy Press (2001)

Two systematic reviews published in 2009 reaffirm the academy’s findings: 

Ospina, M., Krebs Seida, J., Clark, B., Karkhaneh, M., Hartling, L., Tjosvold, L., Vandermeer, B., Smith, V. (2008) Behavioural and Developmental Interventions for Autism Spectrum Disorder: A Clinical Systematic Review, PLoS ONE 3(11): e3755. doi:10.1371/journal.pone.0003755.
“As no definitive behavioural or developmental intervention improves all symptoms for all individuals with ASD, it is recommended that clinical management be guided by individual needs and availability of resources.”

Seida, Ospina, Karkhaneh, Hartling, Smith, and Clark. Developmental Medicine and Child Neurology, 2009, 51.95-104 Systematic reviews of psychosocial interventions for autism: an umbrella review

The second metaanalysis concluded that, “Current evidence does not support ABI [Applied Behavior Intervention] as a superior intervention for children with ASD.”

Spreckley, M., Boyd, R. (2009) Efficacy of Applied Behavioral Intervention in Preschool Children with Autism for Improving Cognitive, Language, and Adaptive Behavior: A Systematic Review and Meta-analysis. The Journal of Pediatrics, 154(3): 338-344.
“Currently there is inadequate evidence that ABI has better outcomes than standard care for children with autism.”

Reichow B., Volkmar, Cicchetti, 2008 Development of the Evaluative Method for Evaluating and Determining Evidence-Based Practices in Autism J Autism Dev Disord 38:1311   
Created an evaluation method which can be used across research methodologies.  Conclusion is that no treatments for autism can be considered evidence based

Odom 2009 Evaluation of Comprehensive Treatment Models for Individuals with Autism Spectrum Disorders J Autism Dev Disord
“There are two classifications of intervention:  focused intervention practice (intent of changing targeted behavior) and comprehensive treatment models (designed to achieve a broader learning or developmental impact)” “To realize the benefits of CTMs…one must look to a broader set of information than usually found in research studies.  To enhance the research to practice process, practitioners’ implementation of the CTM is a necessary feature.”  “Evaluation differs from research in that its purpose is to provide information that informs decision making.”  Across all CTMs, developmental and behavioral, “the published evidence of efficacy was not strong.”

Interagency autism Coordinating Committee Strategic Plan for Autism Spectrum Disorder Research, IACC of the US Dept of HHS 2009, 2010
“A wide range of treatment and intervention options are available for children and adults with ASD…….  For all of these interventions, there is a range of improvement, with some people making profound gains and others showing little response.  We do not know how to predict which people will benefit from any of the available treatments.”

Current research and new technologies

Because of the alarming increase in incidence of autism, there is urgent interest and active research from a wide array of perspectives. There are many researchers actively studying methods which incorporate developmental principles and are looking at ways to measure complex social interactions.

Autism is now recognized as a disorder of integration of various distinct brain functions. Research investigation is focused on deficits in neuronal communication as a basis of the wide array of behavioral manifestations of the disorder.  Developmental intervention is based upon the use of affective interactions to enhance integration of sensory-regulatory, communication and motor systems.  Neuro-imaging techniques and EEG are beginning to be used in research to provide important ways of showing how experience affects developing brains.

Siegel has shown how attuned relationships in infancy change brain structure in ways that later affect social and emotional development.

Siegel, D. (2001). Toward an interpersonal neurobiology of the developing mind: attachment relationships, “mindsight,” and neural integration. Infant Mental Health Journal, 22, 67-94.

Parent Choice

Part of the definition of “evidence base” is clinical experience. While research efforts continue to explore the etiology, biology, and efficacy of treatment approaches for autism, clinical experience also continues to accumulate.  DIR/Floortime programs have high family satisfaction ratings and are widely utilized throughout the world as an effective framework for assessment and intervention.  

A review by the National Institute of Mental Health (NIMH) states, “There is no single best treatment package for all children with ASD.  Decisions about the best treatment, or combination of treatments, should be made by the parents with the assistance of a trusted expert diagnostic team.”   

NIMH. (June 2, 2009). Autism Spectrum Disorders (Pervasive Developmental Disorders. Retrieved June 8, 2009, from http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml

Because of the wide range of individual differences in children with autism, and the many unique relationships within families, it is necessary and proper for parents to have the information and options necessary to make informed choices about the type of services their child will receive. DIR/Floortime has a solid base of empirical evidence, and is widely used for children of all ages and abilities. Evidence based practice means the clinician can utilize all types of information including clinical expertise, and a family’s individual values and preferences, in addition to published research. There is ample evidence for the effectiveness of DIR/Floortime to support an informed parent choice.