DIRFloortime® and Complementary Therapies: A Guide for Parents

Children with developmental disabilities, especially those on the autism spectrum, often struggle to meet their milestones and frequently require intensive support to grow and thrive. 

Traditionally, professionals see these gaps in milestones as checklists they need to tick, with each area of development (e.g., cognitive, motor, social) seen as separate from each other. This view led to treatments that isolated and focused solely on specific skills, such as learning letters or improving eye contact, without integrating these skills meaningfully into the child’s daily life.  

The DIR Floortime^® model is a holistic approach that recognizes that learning and growth happen within a child’s emotional experience. It identifies the child’s developmental stage, meets them there, and helps them progress through meaningful relationships and connections.This article explores the DIR Floortime^® model, its practical applications, and alternative approaches that can complement or serve as alternatives to DIR Floortime^® for your child.

What is DIRFloortime^® (DIR^®)? 

Origins and Overview

The DIR^® model was developed by Dr. Stanley Greenspan, MD, and Serena Wieder, PhD, in 1989. DIR^® stands for Development, Individual differences and Relationship-based.

Development: The DIR^® model describes a unique developmental process called functional emotional developmental capacities (FEDCs), which lay the foundation for the child’s learning and development.

The emotional experiences that occur during the different FEDCs help the child develop skills and their sense of self. Here are the six key FEDCs or milestones [1]:

• Self-regulation and interest in the world (0 to 3 months)
• Engaging and Relating (2 to 7 months)
• Intentionality and Two-Way Communication (3 to 10 months)
• Complex Communication and Shared Problem Solving (9 to 18 months)
• Using Symbols and Creating Emotional Ideas (18 to 48 months)
• Logical Thinking and Building Bridges between Ideas ( 3 to 4 1/2 years)

Individual differences: The model considers the child’s unique way they take in, respond to, process, and comprehend their world.

Relationship-based: The DIR^® model emphasizes how the emotional aspect of relationships promotes development.

Floortime therapy, or DIRFloortime^®, is an intervention approach based on the DIR^® model. The Floortime^® approach helps create interaction between the parent and the child through play/interaction on the floor.

During play, parents and professionals meet the child at their current developmental level and follow the child’s lead, following their natural interests. These lead to interactions that help build their existing skills and create more complex interactions.

Who Can Benefit?

All age groups and abilities may benefit from the DIRFloortime^® approach. However, this intervention program is most often used for children on the autism spectrum and children with other developmental disorders.

Evidence and Effectiveness

A 2023 systematic review found that home-based DIRFloortime^® resulted in substantial progress in different levels of functioning in children with autism [2]. These include improvements in communication, daily living skills, and emotive functioning [2]. Another study done in 2023 found that the approach effectively improved social skills and emotional regulation among children with autism [3].

Similarly, a 2021 study that followed preschool children with ASD who underwent 18 months of DIR Floortime found improvements in the children’s functional and emotional capacities, demonstrating the effectiveness of the intervention [4]. 

Aside from improving children’s social and emotional regulation skills, another study found that DIRFloortime^®  improved parent-child social interaction among children with ASD and their parents [5].

Practical Aspects of DIRFloortime^® (DIR®) 

What is the Time Commitment Required by DIRFloortime^®?

The time you need to commit depends on the intervention plan your child will have. DIR^® has different types or parts. After the assessment, a child participates in a range of DIR^® model types, including home and school interactions, playdates with peers, and specific therapies such as occupational therapy (OT) and speech therapy (ST). 

Floortime^® sessions typically consist of two to five hours of playtime per session. Additionally, children are encouraged to have three to four playdates with peers each week. The frequency of specific therapy sessions can vary, ranging from once a week to several times a week, depending on the child’s individual needs.

Where It Can Be Practiced?

DIRFloortime^®  can be practiced at home, in school, or in a professional setting.

Can it be customized?

Certified and trained DIRFloortime^® professionals provide a customized intervention plan tailored to meet the child’s individual needs. Aside from different types of home and school interactions under DIRFloortime^®, the program typically involves a multidisciplinary strategy that may include the following traditional therapy services:

• Speech therapy (ST)
• Oral motor therapy
• Occupational therapy
• Physical therapy
• Developmental Play Therapy/Psychotherapy
• Peer play/playdates

In addition to these, alternative therapies may also be explored and utilized, including listening therapy programs like Soundsory^® and Forbrain^®.

Who Delivers DIRFloortime®?

A DIRFloortime^® professional must receive training and certification from the Interdisciplinary Council on Development and Learning (ICDL). Typically, DIRFloortime^® certified professionals include OTs, STs, psychologists, social workers, counselors, music therapists, and professionals in related fields. 

What are alternative or complementary approaches to DIR^®?

Introduction to Soundsory^®

Soundsory is an auditory therapy tool designed to improve sensory integration and motor skills. It is especially beneficial for children who need help with sensory processing, coordination, and overall motor function.

Soundsory uses a combination of rhythmic music and bone-conduction technology to stimulate the brain and body, helping to enhance neural pathways associated with movement and sensory perception. 

Children can participate in the DIRFloortime^® program and traditional therapies, including sensory integration therapy, while wearing a Soundsory^® unit. This can be particularly helpful for children who struggle with balance, coordination, or sensory sensitivities, as it helps them better understand and respond to sensory information. Soundsory^® can also aid in the development of motor planning and execution.

Verified Amazon user S&A shared how Soundsory^® helped improve her child’s sensory challenges. She shared, “She is definitely more aware of what her body needs physically. We have tried a lot of different things to help her better navigate her environment and could not recommend this more. Understanding the cues her own body is giving her has helped her emotionally in connecting with others and showing empathy.”

Introduction to Forbrain^®

Forbrain^® is an auditory feedback tool that enhances speech clarity and cognitive functions. Children in capacity/milestone five or higher can significantly benefit from this tool. For example, children at capacity 5 begin to expand their vocabulary, name their intentions and feelings, and become increasingly fluent.

Forbrain^®  can promote better interactions by allowing the child to hear themselves verbalize their ideas. This auditory feedback helps children focus more on their speech and process it better. Additionally, Forbrain can improve attention, comprehension, and memory, which are essential skills for learning and development.

The case of Garrett, a 9-year-old boy with the verbal skills of a three year old, is an excellent example of how Forbrain^® can help. When he started using Forbrain^®, his mother, Brenda, noted that Garrett would enunciate his words. “Words are becoming understandable and do not all run together to make one large word,” shared Brenda.

	Forbrain®	Soundsory®	DIRFloortime®
Duration	20 minutes per day	30 minutes per day	2 to 5 hours per day
Location	At home or in a clinical setting	At home or in a clinical setting	At home or in a clinical setting
Method	Auditory feedback through bone-conduction headphones	Rhythmic music and exercises through air and bone-conduction headphones and dynamic filter	Interactive, play-based therapy
Benefits	Enhances speech clarity and cognitive functions; improves attention, comprehension, and memory	Improves motor, cognitive, and sensory integration through multi-sensory stimulation	Guides the child through developmental milestones through a fun, engaging process while targeting skills like communication, problem-solving, and self-regulation

Practical Tips for Parents 

Equipment Needed for DIR®

What’s great about Floortime^® is that it doesn’t require expensive equipment and tools. It encourages parents to get down on the floor and play with their children. You’re not limited to toys. During the play session, you can use your body, voice, and the objects you already have in your house (tables, chairs, blankets, books). 

The most important thing to remember is that the play should be meaningful. If you want to purchase toys, look for activities and themes that align with the child’s interests. This could include their favorite characters and activities. You can also buy toys that provide exploration, engagement, and interaction opportunities. Choose those that would encourage building new skills (scaffolding), such as higher-order thinking skills like problem-solving and motor planning.

Some great toy options include:

• Play-Doh
• Finger paint
• Colored wax sticks
• Balance board
• Tents and tunnels
• Therapy ball 
• Wooden blocks
• Puppets
• Pretend play tools (e.g., swords, wands, kitchen sets, doctors kits)
• Dolls and doll houses
• Pretend food products

Specialized tools like Soundsory^® and Forbrain^® can also be used to complement DIRFloortime^®. These tools can enhance sensory processing, auditory feedback, and overall engagement during play sessions, further supporting the child’s developmental progress.

Cost Considerations

In DIRFloortime^®, a certified professional designs the overall program based on their assessment. This includes specific therapies and teaching the caregivers how to do Floortime^®.

The cost of a single Floortime^® session can range from $80 to $250 per hour, depending on your location and the professional’s skills and qualifications. You might need to pay separately for specific therapies, like occupational therapy and speech therapy, along with the cost of Floortime^®.

However, you don’t always need professionals in your home to implement Floortime^®. You can get Floortime^® coaching, attend parent courses and workshops, and read books to learn Floortime^® techniques you can implement at home. 

Implementing DIR® at Home

Implementing Floortime^® at home requires creating a calm, supportive environment so that meaningful connections and interactions might occur. 

Here are some tips that can help:

• Be present. Tune in to your child and give them your full attention. Forget about any agenda you have in mind and observe what they are doing and how they enjoy it.
• Observe your child’s sensory processing. Observe how your child interacts with their environment. Are they sensitive to certain stimuli or crave a particular input? Knowing this can help you plan your Floortime^® sessions and your child’s daily activities.
• Create an interactive environment. Create a safe, comfortable space. Ensure it’s not too bright and has no distractions and electronics around. Keep toys and materials within reach. Make sure to incorporate toys and activities that your child prefers.
• Follow your child’s lead. Observe your child and use their interests and preferences as a jumping point for interaction. Join them in their play by imitating their actions and using open-ended questions to facilitate communication.
• Build on the child’s play ideas. Extend and expand their drama. Doing so can help your child expand their play repertoire, develop new skills, and encourage higher-order skills like problem-solving and imaginative thinking. At the same time, introduce new experiences, activities, and challenges to promote your child’s development and help them achieve new milestones.
• Communicate well. Use simple language and be generous in your gestures and facial expressions to engage your child. Encourage them to express themselves by waiting for their response, whether through speech, gestures, signs, or other methods.
• Use everyday activities as learning opportunities. Incorporate DIR^® principles into daily routines, such as mealtime or getting dressed, to make learning a continuous, natural process.
• Involve the whole family. Encourage siblings and other family members to participate in Floortime^® sessions. This can strengthen bonds and create a supportive environment for the child.

Soundsory^® is a home-based program that you can easily add into your Floortime^® routine. Not only does it complement Floortime^® and other standard programs, but it can also enhance sensory processing and boost overall engagement, providing additional support for your child’s developmental journey. Explore Soundsory^® to see how it can benefit your family.

FAQs : DIRFloortime® Approach for Children

What is the age range for DIRFloortime®?

DIRFloortime^® can be used for individuals of all ages.

What is the difference between ABA and DIRFloortime®?

Applied behavioral analysis (ABA) is based on behaviorism and focuses on changing observable behaviors, typically through the use of reinforcements and punishments. An ABA session is often therapist-led and focuses on teaching particular skills.

DIRFloortime^® is a developmental approach that aims to understand the child’s unique profile and promote the developmental process by building on the child’s unique interests and motivations. It is child-led, play-based, and more focused on emotional connection and development. 

Does insurance pay for DIRFloortime®?

The coverage for DIRFloortime^® depends on your insurance provider and your state of residence. Generally, health insurance plans are required by law to cover autism services. However, some health insurance providers do not cover DIRFloortime^® because they view it as a coaching or educational service or an experimental treatment. States like New Jersey, Illinois, and Minnesota offer comprehensive DIR^® benefits.

Medicaid plans should cover all medically necessary treatments for children under 21. If a doctor determines that DIRFloortime^® is medically necessary for a child, Medicaid must cover it.

The Senate Bill 805 aims to expand insurance coverage for autism care services to include all evidence-based developmental interventions, including DIRFloortime^® [6]. This bill is scheduled to be implemented by July 2026.

References 

1. The International Council on Development and Learning, Inc. (n.d.). Functional emotional development. Last consulted July 24, 2024. https://www.icdl.com/dir/fedcs/
2. Divya, K. Y., Begum, F., John, S. E., & Francis, F. (2023). DIR/Floor Time in Engaging Autism: A Systematic Review. Iranian Journal of Nursing and Midwifery Research., 28(2), 132. https://doi.org/10.4103/ijnmr.ijnmr_272_21
3. Barghi, F., Safarzadeh, S., Marashian, F. S., & Bakhtiarpour, S. (2023). Effectiveness of DIR/Floor Time Play Therapy in Social Skills and Emotion Regulation of Children with Autism Spectrum Disorder. Middle East Journal of Rehabilitation and Health Studies, 11(2). https://doi.org/10.5812/mejrh-138491
4. Pacheco, P., Pacheco, M., & Molini-Avejonas, D. (2021). Study of 18 months of follow up dir floortime intervention in preschool children with autism spectrum disorder (ASD). European Psychiatry, 64(S1), S503–S503. doi:10.1192/j.eurpsy.2021.1346
5. Casler, M., Barenberg, B., & Hasselbrook, B. (2022). What is the effectiveness of a DIR/Floortime occupational therapy intervention program for improving parent-child social interaction in children with autism spectrum disorder? https://researchworks.creighton.edu/esploro/outputs/other/What-is-the-effectiveness-of-a/991005932130402656#file-0
6. Portantino’s Autism Treatment Bill was signed by Governor Newsom. (2023). https://sd25.senate.ca.gov/news/2023-10-11/portantino’s-autism-treatment-bill-signed-governor-newsom