Evidence Base for the DIRFloortime Approach

Diane Cullinane, M.D., FAAP

Facult , Interdisciplinar Council on Development and !earnin"

DIRFloortime is a #a of relatin" to a child in #hich #e reco"ni$e and respect the emotional e%perience and e%pressions of the child, sho#n in their actions, ideas, and intentions, and interact in a #a that helps the child use their natural emotions #ith a "reater sense of purpose, &uildin" their capacit to en"a"e and communicate, at increasin"l comple% levels of functional development. ' pe of (upport for developmental approaches DIR)Floortime is derived from over *+ ears of stud and research a&out child development from the fields of ps cholo" , medicine, and education, and includes the areas of lan"ua"e, attention, mental health, attachment, infant development, sensor processin", and motor development. Evidence-based practice means a decision making process which integrates the best available scientifically rigorous research, clinical expertise, and individuals characteristics. Evidence-based practice is an approach to treatment rather than a specific treatment. Evidence-based practice promotes the collection, interpretation, integration, and continuous evaluation of valid, important, and applicable individual- or family-reported, clinically-observed, and research-supported evidence. he best available evidence, matched to infant or toddler circumstances and preferences, is applied to ensure the !uality of clinical "udgments and facilitates the most cost-effective care. #$% railer &ill '(()*

What to measure?
A startin" point to measure effectiveness of intervention is to determine the factors to &e measured. 'his is a ma,or challen"e in the field of developmental disa&ilities. -enerall , &ehavioral approaches measure specific tar"eted &ehaviors. More recentl , there has &een a focus on measurin" spontaneous interactions and "enerali$ation of s.ills, #hich presents ne# challen"es in measurement. In contrast, developmental pro"rams tar"et underl in" capacities, or /core deficits0 as the focus of intervention, #ith pro"ress evident in a comple% arra of chan"es in interactive &ehavioral patterns. +evelopmental approaches seek to measure changes in an individuals capacity for, -hared attention %bility to form warm intimate and trusting relationships he ability to initiate.rather than respond/ using intentful actions and social engagement0 spontaneous communication he ability to participate in reciprocal .two-way, mutual/ interactions while in a range of different emotional states 1roblem solving through a process of co-regulation, reading, responding and adapting to the feelings of others $reativity hinking logically about motivations and perspective of others

+eveloping an internal personal set of values

'hese developmental measures are more closel ali"ned to the dia"nostic criteria for PDD)autism than those often used in older research such as I2, performance on earl academic s.ills and responsive &ehaviors. 'he 3ational Research Council stated in 4++15 6More appropriate outcome measures are improvement in initiation of spontaneous communication in functional activities, and "enerali$ation of lan"ua"e across activities people, and settin"s7
!ord, Catherine8 Mc-ee, 9ames :Editors;. Committee on Educational Interventions for Children #ith Autism. Educating $hildren with %utism. Division of Behavioral and (ocial (ciences and Education, 3ational Research Council. <ashin"ton, DC5 3ational Academ Press :4++1; p 41=

An additional challen"e confrontin" all researchers in the field is the #ide diversit of individuals #ith a dia"nosis of autism or a related disorder. <arren, >. et. al. in 6% -ystematic 2eview of Early 3ntensive 3ntervention for %utism -pectrum +isorders7 stress the need for further research 6to &etter characteri$e su&"roups of children #ho respond differentl to individual approaches7 and conclude that 6'here is not et ade?uate evidence to pin@point specific &ehavioral intervention approaches that are the most effective for individual children #ith A(Ds.7
<arren, >. et al, Pediatrics, Aol 14= 3o* Ma 4+11

Developmental models emphasi$e individual differences and the need to tailor intervention to the uni?ue &iolo"ical profile of the child and to the uni?ue characteristics of the parent@child interaction. Research is challen"in" &oth &ecause &oth the factors &ein" measured are comple% and &ecause of the #ide ran"e of individual differences in the population. In considerin" the evidence for DIR)Floortime, it is important to appreciate the challen"es to stud in" a comple% model, and to consider the lon" histor of stud on the effectiveness of various facets of a developmental frame#or.. 'hese can &e summari$ed & loo.in" at the three ma,or aspects of the DIR)Floortime approach5 6D7@ developmental frame#or., 6I7@ individual differences, and 6R7@relationship and affective interactions. Because of the #ide ran"e of individual differences in autism, there is more interest in usin" sin"le@su&,ect research desi"n. A sin"le su&,ect stud desi"n #as used to evaluate the effectiveness of Floor 'ime Pla #ith a B.C ear old &o #ith autism. 'he stud used an o&servation and intervention phase, and utili$ed circles of communication as the measure of chan"e. Results sho#ed a si"nificant improvement usin" Floor 'ime pla strate"ies, and mother0s ,ournal included insi"hts on the chan"es o&served.
Dionne and Martini, 2evue canadienne dergotherapie8 9une 4+11 =D :B;

D Developmental
A developmental approach is founded on #or. & ma,or developmental theorists such as Pia"et, A "ots. , Eri.son, and Eohl&er". A developmental approach considers &ehavior and learnin" in the "reater conte%t of a developmental or chan"in" process. DIR theor #as first descri&ed & Dr. -reenspan in 1F=* and #as further developed over the ne%t 4+ ears. Ge received hi"h honors and acclaim for his #or. includin" American Ps chiatric AssociationHs hi"hest a#ard for child ps chiatr research.
-reenspan, (.I, A Consideration of (ome !earnin" Aaria&les in the Conte%t of Ps choanal tic 'heor , :1F=*; -reenspan, (.I. Intelli"ence and Adaptation, :1F=F; -reenspan, (.I. Ps chopatholo" and Adaptation in Infanc and Earl Childhood :1FD1; -reenspan, (.I. First Feelin"s :1FD*;, -reenspan, (.I. 'he Essential Partnership :1FDF; -reenspan, (.I. 'he Development of the E"o :1FDF; -reenspan, (.I. Infanc and Earl Childhood :1FF4;

In 1FF=, Dr. -reenspan and (erena <eider pu&lished, 'he Child #ith (pecial 3eeds5 Encoura"in" Intellectual and Emotional -ro#th and in 4++C the pu&lished, En"a"in" Autism. In 1FF=, the reported the results of an e%tensive chart revie# of 4++ children #ith autism #ho had received DIRFloortime. 'his sho#ed the promise of the DIR)F' approach5 'he "oal of the revie# #as to reveal patterns in presentin" s mptoms, underl in" processin" difficulties, earl development and response to intervention in order to "enerate h potheses for future studies. 'he chart revie# su""ests that a num&er of children #ith autistic spectrum dia"noses are, #ith an appropriate intervention pro"ram, capa&le of empath , affective reciprocit , creative thin.in", and health peer relationships8 that an intervention approach that focuses on individual differences, developmental level, and affective interaction ma &e especiall promisin"8
-reenspan, (.I. and <ieder, (. :1FF=; Developmental patterns and outcomes in infants and children #ith disorders in relatin" and communicatin"5 A chart revie# of 4++ cases of children #ith autistic spectrum dia"noses. 9ournal of Developmental and !earnin" Disorders 15D=@1I1.

D ears later, the reported the follo#@up of a su&"roup of children, sho#in" that it is possi&le for children #ith autism to &ecome empathetic, creative, and reflective thin.ers.
-reenspan, (.I. and <ieder, (. :4++*; Can Children #ith Autism Master the Core Deficits and Become Empathetic, Creative and ReflectiveJ A 'en to Fifteen Kear Follo#@up of a (u&"roup of Children #ith Autism (pectrum Disorders :A(D; <ho Received a Comprehensive Developmental, Individual@ Difference, Relationship@Based :DIR; Approach. he 4ournal of +evelopmental and 5earning +isorders ).

Previous approaches usin" &ehavioral principles, relied upon outside motivators on the premise that children #ith autism did not have their o#n motivation to participate in social interaction or to learn. 'he DIR)Floortime approach revealed that all children #ill sho# purpose and initiative, and #ill see. close social relationships #hen provided #ith interactions #hich respect their interests and are tailored to their individual differences.

'he DIR)Floortime approach has provided a developmental frame#or. that has &een studied and found to &e accurate and effective in understandin" &ehavior. 'he #idel used &ayley -cales of 3nfant development has adopted the DIR milestones as the measure of social@emotional development throu"h a process of careful standardi$ation across populations. 'he follo#in" research studies report the effectiveness of developmental approach5
Ro"ers, (. and D. Delalla. :1FF1;. 6A comparative stud of the effects of a developmentall &ased instructional model on oun" children #ith autism and oun" children #ith other disorders of &ehavior and development.7 opics in Early $hildhood -pecial Education 115 4F@I=. 9ocel n, !., et al. :1FFD;. 'reatment of children #ith autism5 a randomi$ed controlled trial to evaluate a care"iver &ased intervention pro"ram in communit da @care centers. +evelopmental and &ehavioral 1ediatrics, 6), B4C@BBI. 3ational Research Council and Institute of Medicine :4+++;. 7rom 8eurons to 8eighborhoods, he -cience of Early $hildhood +evelopment. 9ac. P. (hon.off and De&orah A. Phillips, eds. Board on Children, Kouth, and Families, Commission on &ehavioral and (ocial (ciences and Education. <ashin"ton, DC5 3ational Academ Press. B. G#an" L C. Gu"hes :4+++; 6Increasin" Earl (ocial Communicative (.ills of Prever&al Children #ith Autism throu"h (ocial Interactive 'rainin".7 9ournal of the Association for Persons #ith (evere Gandicaps, Aol 4*, pp. 1D@4D. (alt 4++4 he -cottish $entre for %utism preschool treatment programme 'he 3ational Autistic (ociet Aol C :1; BB A developmentall &ased earl intervention pro"ramme8 treatment "roup sho#ed si"nificant improvement in ,oint attention, social interaction, imitation, dail livin" s.ills, motor s.ills and an adaptive &ehaviour composite. Aldred, C., -reen, 9., Adams, C. :4++I; A ne# social communication intervention for children #ith autism5 pilot randomi$ed controlled treatment stud su""estin" effectiveness, 4ournal of $hild 1sychology 9 1sychiatry and %llied +isciplines, I*:D;5 1I4+@B+ RC' pilot stud , d adic social communication treatment. 'he active treatment "roup sho#ed si"nificant improvement on ADM( total score, social interaction, lan"ua"e, parent@child interaction. Aismara, Colom&i, L Ro"ers. :4++F;. Can one hour per #ee. of therap lead to lastin" chan"es in oun" children #ith autismJ %utism, Aol 1B :1;, FB@11*

In 4++=, (olomon reported a pilot stud on the Pla Pro,ect #hich sho#ed si"nificant increases in child su&scale scores on the FEA( after an D@14 month pro"ram usin" Floortime.
(olomon, R., 9. 3echeles, C. Ferch, and D. Bruc.man. 6Pilot stud of a parent trainin" pro"ram for oun" children #ith autism5 'he P.!.A.K. Pro,ect Gome Consultation pro"ram.7 %utism 11, no. B :4++=; 4+*@ 44I.

In 9une 4+11, Pa,are a pu&lished a pilot RC' of DIR)Floortime #ith preschool children #ith A(D. Results sho#ed improvements in FEA(, CAR(, and the functional emotional ?uestionnaires, confirmin" the results of the (olomon 4++= stud .

Pa,are a and 3opmanee,umruslers, Autism, Aol 1*:4; 1@1*. 9une 4+11.

Gistoricall , &ehavioral approaches have not focused on relationships or individual differences. Pivotal Response 'rainin" or PR' a form of naturalistic &ehavioral treatment is a form of &ehavioral intervention that is &ased on follo#in" the child0s interest to increase motivation, and incorporates some developmental principles into a &ehavioral model.
Eoe"el, R., Eoe"el, !., and Mc3erne , E. :4++1;. Pivotal areas in intervention for autism. 4ournal of $linical $hild 1sychology, :(, 1F@B4.

Recent studies have sho#n efficac in &lendin" developmental and &ehavioral approaches5
Da#son :4+1+; 2andomi;ed controlled trial of an intervention for oddlers with autism, he Early -tart +enver <odel, Ped514* :1; ED(M is &ased on developmental and applied &ehavioral anal tic principles. Children in the ED(M "roup had 6si"nificant improvements in I2, lan"ua"e, adaptive &ehavior, and autism dia"nosis7 Easari :4+1+; 2andomi;ed $ontrolled $aregiver <ediated 4oint Engagement 3ntervention for toddlers with autism. 9. Autism Dev Disord (i"nificant improvements in ,oint en"a"ement, ,oint attention, and diversit of functional pla acts, #ith maintenance of these s.ills 1 ear post@intervention8 intervention #as focused on 6the development of pla routines in #hich the adult could follo# in on the child0s interests maintain and then e%pand upon their pla activities.7 6'he approach involved developmental procedures of responsive and facilitative interaction methods as #ell as aspects of applied &ehavior anal sis.7 !anda, R., Golman, E., M03eill, A., and (tuart, E. :4+11;. Intervention tar"etin" development of sociall s nchronous en"a"ement in toddlers #ith autism spectrum disorder5 A randomi$ed controlled trial. 4ournal of $hild 1sychology and 1sychiatry, *4, :1;, 1B@41. Nsin" a supplemental developmental curriculum in a classroom pro"ram tar"etin" sociall s nchronous en"a"ement in toddlers #ith autism spectrum disorders, a si"nificant treatment effect #as found for /sociall en"a"ed imitation0, 'his s.ill #as "enerali$ed to unfamiliar conte%ts and maintained throu"h follo#@up at si% months. !a#ton, E and Easari, C. :4+14;. 'eacher@implemented ,oint attention intervention5 Pilot randomi$ed controlled stud for preschoolers #ith autism. 4ournal of $onsulting and $linical 1sychology. D+ :I;, CD=@ CFB. In an inte"rated developmental &ehavioral intervention resulted in increased Initiation and 9oint Attention

4+ authors, representin" 1= ma,or institutions, and B countries colla&orated to #rite a paper #hich outlines principles of assessment and effective intervention for children #ith suspected autism under the a"e of 4. 'he concluded 6Interventions should ultimatel &e directed to#ard specific functional concerns and &e informed & .e developmental principles, includin" the child0s role as an active learner, the social conte%ts of learnin", and the pivotal role of the parent@child relationship.7 'hese principles are &asic tenants of the DIR)Floortime approach.
>#ai"en&aum et al :4++F;, $linical %ssessment and <anagement of oddlers with -uspected autism spectrum disorder, 3nsights from studies of =igh-risk infants.

In 4+1+, <allace and Ro"ers pu&lished a revie# of controlled studies #hich identified four factors #hich #ere most important for effective intervention for infants #ith autism. 'hese #ere5 6:1; parent involvement in intervention, includin" on"oin" parent coachin" that focused &oth on parental responsivit and sensitivit to child cues and on teachin" families to provide the infant interventions, :4; individuali$ation to each infant0s developmental profile, :B; focusin" on a &road rather than a narro# ran"e of learnin" tar"ets, and :I; temporal characteristics involvin" &e"innin" as earl as the ris. is detected and providin" "reater intensit and duration of the intervention.7
<allace Eatherine (. and Ro"ers (all 9. Intervenin" in infanc 5 implications for autism spectrum disorders 9ournal of Child Ps cholo" and Ps chiatr :4+1+;

More and more, intervention models are incorporatin" these elements, #hich are all fundamental features of the DIR)Floortime approach.

I Individual Difference
In the 1F=+s 9ean A res pioneered discoveries a&out innate sensor processin" differences.
A res 9A. :1F=F;. -ensory 3ntegration and the $hild. <estern Ps cholo"ical (ervices. !os An"eles, CA.

'his provided a ne# #a of understandin" movement and re"ulator &ehaviors. In addition this #or. sho#ed that these &iolo"ical differences could &e influenced and chan"ed & specific therapeutic interventions. Mver the past I+ ears, a hu"e &od of research has further descri&ed not onl &iolo"ical differences in sensor @motor processin" &ut further differences in emotional@re"ulator processin". 'he 3ational Research Council of the 3ational Academ of (ciences, in their 4++1 landmar. report, 6Educatin" Children #ith Autism,7 called for tailorin" the treatment approach to the uni?ue features of the individual child.
!ord, Catherine8 Mc-ee, 9ames :Editors;. Committee on Educational Interventions for Children #ith Autism. Educating $hildren with %utism. Division of Behavioral and (ocial (ciences and Education, 3ational Research Council. <ashin"ton, DC5 3ational Academ Press :4++1; p 41=

A :4+11; pilot randomi$ed control stud sho#ed the effectiveness of sensor inte"ration treatment for children #ith autism. Results sho#ed improvement in social responsiveness, sensor processin", functional motor s.ills, and social@emotional factors #ith a si"nificant decrease in autistic mannerisms.
Pfeiffer, B. A., Eoeni", E., Einneale , M., (heppard, M., L Genderson, !. :4+11;. Research (cholars InitiativeOEffectiveness of sensor inte"ration interventions in children #ith autism spectrum disorders5 A pilot stud . American 9ournal of Mccupational 'herap , C*, =CPD*

DIR)Floortime places "reat emphasis on tailorin" intervention to individual differences, consistent #ith the .no#led"e "ained from this research.

R Relationship and Affect

Developmental models have evolved from man ears of discover in the field of infant mental health. Be"innin" in the 1F*+s, there #as a ne# understandin" of the importance of parent@infant interaction, .no#n as attachment theor .
Bo#l& , 9. :1F*1;. <aternal care and mental health. <orld Gealth Mr"ani$ation :<GM;. Mono"raph (eries, no. *1. -eneva5 <orld Gealth Mr"ani$ation. Ains#orth, M., Bell, (.M., L (ta ton, D. :1F=I;. Infant@mother attachment and social development5 (ociali$ation as a product of reciprocal responsiveness to si"nals. In M. Richards, ed., he 3ntegration of the child into a social world. Cam&rid"e5 Cam&rid"e Nniversit Press. (tern, D. :1F=I;. Mother and infant at pla 5 'he d adic interaction involvin" facial, vocal, and "a$e &ehaviors. In M. !e#is and !. Rosen&lum, eds., he effect of the infant on its caregiver . 3e# Kor.5 9ohn <ile L (ons, Inc.

Dr. -reenspan and (erena <ieder contri&uted to the field #ith their stud of the importance of mother@child interactions in hi"h ris. infants.
3ational Center for Clinical Infant Pro"rams :1FD=;. 3nfants in <ultirisk 7amilies. $ase -tudies in 1reventive 3ntervention. (tanle I. -reenspan, (erena <ieder, Ro&ert A. 3over, Alicia !ie&erman, Re"inald (. !ourie, Mar E. Ro&inson, eds. Clinical infant Reports, 3um&er three. International Nniversities Press.

'here is a&undant research confirmin" the importance of parent@child interaction and the value of intervention pro"rams focused on supportin" parent@child relationships. 'his #or. has &ecome hi"hl sophisticated in research methodolo"ies e%aminin" ,oint attention and emotional attunement.
Mundi, P., (i"man M., Easari C. :1FF+;. A lon"itudinal stud of ,oint attention and lan"ua"e development in autistic children. 4ournal of %utism and developmental +isorders 4+511*@14D. Alan Fo"el :1FFB;, +eveloping hrough 2elationships, 'he Nniversit of Chica"o Press. ( nopsis availa&le at http5))###.press.uchica"o.edu)presssite)metadata.eplJmodeQs nopsisL&oo..e Q*4=DC Board on Children, Kouth, and Families, 7rom 8eurons to 8eighborhoods, he -cience of Early $hildhood +evelopment, 9ac. B. (hon.off and De&orah A. Phillips :Eds.;, 3ational Academies Press, <ashin"ton, DC, 4+++, pdf version at ###.nap.edu)catalo".phpJrecordRidQFD4I Afflec., -., et al. :4++1;. Promise of relationship@focused earl intervention in developmental disa&ilities. 4ournal of -pecial Education, 6>, I1B@IB+. Mahone , -. L Perales, F. :4++B;. Nsin" relationship@focused intervention to enhance the social@emotional functionin" of oun" children #ith autism spectrum disorders. opics in Early $hildhood -pecial Education, ':, =I@DC. Mahone , -., and F. Perales. 6Relationship@focused earl intervention #ith children #ith pervasive developmental disorders and other disa&ilities5 a comparative stud . 4ournal of +evelopmental 9 &ehavioral 1ediatrics 4C, :4++I;5 ==@D*. Eim, 9. and Mahone , -. :4++*;. 'he effects of relationship focused intervention on Eorean parents and their oun" children #ith disa&ilities. 2esearch in +evelopmental +isabilities, '>, 11=@1B+.

-erns&acher has sho#n that intervention can chan"e the #a parents interact to increase reciprocit and that these chan"es are correlated #ith chan"es in social en"a"ement and in lan"ua"e.
-erns&acher M.A., :4++C;. 'o#ard a &ehavior of reciprocit . 4ournal of +evelopmental 1rocesses, 6, 1BF@ 1*4. http5))ps ch.#isc.edu)lan")pdf)"erns&acherRreciprocit .pdf

Easari et al. 4++D used a randomi$ed, controlled trial loo.in" at ,oint attention and s m&olic pla in *D children #ith autism. Results indicate that e%pressive lan"ua"e "ains #ere "reater for treatment "roups #hich used developmental approaches compared #ith the control "roup that #as &ased onl on &ehavioral principles.
Easari, Connie8 Paparella, 'an a8 Freeman, (tephann 8 9ahromi, !audan B. 6!an"ua"e outcome in autism5 Randomi$ed comparison of ,oint attention and pla interventions.7 4ournal of $onsulting and $linical 1sychology. Aol =C:1;, Fe& 4++D, 14*@1B=.

Evidence continues to support parent@mediated intervention as effective for the treatment of children #ith autism. A revie# of the literature, #hich included onl randomi$ed controlled trials found evidence for positive chan"e in patterns of parent@child interaction, parent s nchron and su""estive of improvement in child lan"ua"e comprehension and reduction in the severit of children0s autism characteristics.
Parent@mediated earl intervention for oun" children #ith autism spectrum disorders :A(D; :;Revie#; 4+1B 'he Cochrane Colla&oration, Pu&lished & 9ohn <ile and (ons, !td .

A lar"e revie# of over one thousand articles, found evidence of effectiveness for 6Parent@ implemented intervention.7 (tudies are documentin" the importance of the .e relationships in a child0s life as a focus of intervention.
Evidence@Based Practices for Children, Kouth, and Koun" Adults #ith Autism (pectrum Disorder <on", Mdom, et al, :4+1B; Chapel Gill5 'he Nniversit of 3orth Carolina, Fran. Porter -raham Child Development Institute Autism Evidence@Based Practice Revie# -roup.

DIR)Floortime is a ps chod namic approach, #ith affective interactions as the &asis of treatment, and the "oal of increasin" functional capacities. Ps chod namic treatments are inherentl more difficult to measure in ?uantitative terms. (hedler, in 4+1+ authored, he efficacy of psychodynamic psychotherapy in #hich he revie#s man studies and meta@anal ses and refutes the &elief that 6ps chod namic concepts and treatments lac. empirical support or that scientific evidence sho#s that other forms of treatment are more effective.7 Empirical evidence supports the efficacy of psychodynamic therapy. Effect si;es for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as ?empirically supported and ?evidence based. Ge descri&es = features of ps chod namic therap 5 1. Focus on affect and e%pression of emotion 4. E%ploration of attempts to avoid distressin" thou"hts and feelin"s B. Identification of recurrin" themes and patterns

I. Discussion of past e%perience :developmental focus; *. Focus on interpersonal relations C. Focus on therap relationship =. E%ploration of fantas life Althou"h the article is not a&out children #ith autism, it provides the &asic frame#or. of a ps chod namic approach, #hich is the root of developmental approaches to treatment #ith children. Ge descri&es the "oals of this t pe of treatment5 he goals of psychodynamic therapy include, but extend beyond, symptom remission. -uccessful treatment should not only relieve symptoms, but also foster the positive presence of psychological capacities and resources. 'he idea that developmental approaches improve developmental capacities, rather than onl chan"in" specific s.ills or &ehaviors, is a core distinction in measurement for research outcome. 'he outcomes of chan"e in functional capacit are more difficult to measure, and ma.e comparisons across different fields of literature more challen"in". 'his article discusses previous &road revie#s, includin"5 Cochrane report 4++C8 meta@anal sis 4++D, 4++F5 hese meta-analyses represent the most recent and methodologically rigorous evaluations of psychodynamic therapy. Especially noteworthy is the recurring finding that the benefits of psychodynamic therapy not only endure but increase with time, a finding that has now emerged from at least five independent metaanalyses. 'here is no# clear evidence emer"in" that ps chod namic approaches are in fact effective. DIR)Floortime is in lar"e part "rounded in the understandin" and appreciation of ps chod namic interactions &et#een parents and children.

Claims
(#eepin" claims are made a&out the effectiveness of &ehavioral approaches, specificall ABA, ho#ever, a careful readin" of research reveals that evidence of effectiveness is not so definitive. In 4++1, 'he 3ational Academ of (ciences report concluded that there is some evidence for &oth developmental approaches and &ehavioral approaches &ut no definitive evidence for either. 'here have &een no comparative studies &et#een these t#o approaches.
!ord, Catherine8 Mc-ee, 9ames :Editors;. Committee on Educational Interventions for Children #ith Autism. Educating $hildren with %utism. Division of Behavioral and (ocial (ciences and Education, 3ational Research Council. <ashin"ton, DC5 3ational Academ Press :4++1;

'#o s stematic revie#s pu&lished in 4++F reaffirm the academ 0s findin"s5

Mspina, M., Ere&s (eida, 9., Clar., B., Ear.haneh, M., Gartlin", !., ',osvold, !., Aandermeer, B., (mith, A. :4++D; Behavioural and Developmental Interventions for Autism (pectrum Disorder5 A Clinical ( stematic Revie#, 15o- @8E B:11;5 eB=**. doi51+.1B=1),ournal.pone.+++B=**.

%s no definitive behavioural or developmental intervention improves all symptoms for all individuals with %-+, it is recommended that clinical management be guided by individual needs and availability of resources.
(eida, Mspina, Ear.haneh, Gartlin", (mith, and Clar.. Developmental Medicine and Child 3eurolo" , 4++F, *1.F*@1+I ( stematic revie#s of ps chosocial interventions for autism5 an um&rella revie#

'he second metaanal sis concluded that, 6Current evidence does not support ABI SApplied Behavior InterventionT as a superior intervention for children #ith A(D.7
(prec.le , M., Bo d, R. :4++F; Efficac of Applied Behavioral Intervention in Preschool Children #ith Autism for Improvin" Co"nitive, !an"ua"e, and Adaptive Behavior5 A ( stematic Revie# and Meta@ anal sis. he 4ournal of 1ediatrics, 1*I:B;5 BBD@BII.

$urrently there is inade!uate evidence that %&3 has better outcomes than standard care for children with autism.
Reicho# B., Aol.mar, Cicchetti, 4++D +evelopment of the Evaluative <ethod for Evaluating and +etermining Evidence-&ased 1ractices in %utism 9 Autism Dev Disord BD51B11

$reated an evaluation method which can be used across research methodologies. $onclusion is that no treatments for autism can be considered evidence based Because of the challen"es in identif in" uniform treatment "roups, isolatin" treatments, ensurin" fidelit of treatment approaches, and the lac. of validated measurement tools, man authors have stated that it is too soon for meanin"ful randomi$ed clinical trails.
Michelle -arcia <inner, A Politicall Incorrect !oo. at Evidence@&ased Practices and 'eachin" (ocial (.ills :4++D; (. 9. Ro"ers L !.A. Aismara :4++D;, 6Evidence@&ased Comprehensive 'reatments for Earl Autism,7 9ournal of Clinical Child and Adolescent Ps cholo" , p B=, pp D@BD Costa - L <itten MR :Au"ust 4++F;. Pervasive Developmental Disorders. In Mo#der, Ru&inson L Kasi. :Eds;, Evidence-&ased 1ractice in 3nfant and Early $hildhood 1sychology. <ile .

Dre# 4++4, and Mahone 4++B have su""ested that other methodolo" &e considered in lieu of randomi$ed controlled trials, such as norm referenced scores, and lo"ic models.
Dre#, A., et al. :4++4;. A pilot randomi$ed control trial of a parent trainin" intervention for preschool children #ith autism5 preliminar findin"s and methodolo"ical challen"es. European $hild 9 %dolescent 1sychiatry, 66, 4CC@4=4. Mahone , -. and Perales, F. :4++B;. Nsin" relationship@focused intervention to enhance the social@ emotional functionin" of oun" children #ith autism spectrum disorders. opics in Early $hildhood -pecial Education, ':.

Dr. -ranpeesheh, #ho serves as a First Aice Chair of the Autism (ociet of America, and has #ritten e%tensivel a&out ABA states5 63ncreasingly, researchers have been suggesting that the idea that there is a best treatment for autism is counterproductive and misleadingA. he remarkable heterogeneity displayed by people with autism calls into !uestion the idea that randomi;ed clinical trials .2 $s/ should, at the time of the development of the field, be considered the gold standard for evaluation whether a specific treatment has merit.
Carr, E., -ranpeesheh, D., -rossman, !. 'he Future of Applied Behavior Anal sis in Autism (pectrum Disorder. Autism Advocate 4++D8 I5*+@*D.

Mdom 4++F Evaluation of $omprehensive reatment <odels for 3ndividuals with %utism -pectrum +isorders 9 Autism Dev Disord 1+

 here 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/ o reali;e the benefits of $ <sAone must look to a broader set of information than usually found in research studies. o enhance the research to practice process, practitioners implementation of the $ < is a necessary feature. Evaluation differs from research in that its purpose is to provide information that informs decision making. %cross all $ <s, developmental and behavioral, the published evidence of efficacy was not strong. Intera"enc autism Coordinatin" Committee (trate"ic Plan for Autism (pectrum Disorder Research, IACC of the N( Dept of GG( 4++F, 4+1+ % wide range of treatment and intervention options are available for children and adults with %-+AA. 7or all of these interventions, there is a range of improvement, with some people making profound gains and others showing little response. Be do not know how to predict which people will benefit from any of the available treatments.

Current research and new technologies

Because of the alarmin" increase in incidence of autism, there is ur"ent interest and active research from a #ide arra of perspectives. 'here are man researchers activel stud in" methods #hich incorporate developmental principles. '#o e%amples are5 Dr. Ric. (olomon is doin" a randomi$ed control trial stud on the Pla Pro,ect. 'he 3ational Institute of Mental Gealth has "ranted 1.D* million dollars, to e%ecute a Phase II stud . 'he Pla Pro,ect has partnered #ith Easter (eals and Michi"an (tate Nniversit to conduct this three ear lon" stud . 'he Brid"e Pro,ect 4++F is a ,oint effort of the Brid"e Colla&orative, a "roup comprised of NC(D, Rad ChildrenHs Gospital, the (an Die"o Re"ional Center, the Gar&or Re"ional Center :'orrance, !on" Beach;, Eaiser Permanente, parents, and private providers, and others. 'he #ere a#arded a U4*+,+++ 3IG R+1 "rant for a pilot stud , #ith a clear path to#ard a U4,*++,+++ "rant, to implement evidenced &ased screenin" and intervention in (outhern California. 'he have chosen Pro,ect ImPAC' and added components of en"a"ement, individual differences, and reflective process. Autism is no# reco"ni$ed as a disorder of inte"ration of various distinct &rain functions. Research investi"ation is focused on deficits in neuronal communication as a &asis of the #ide arra of &ehavioral manifestations of the disorder. Developmental intervention is &ased upon the use of affective interactions to enhance inte"ration of sensor @re"ulator , communication and motor s stems. 3euro@ima"in" techni?ues are &e"innin" to &e used in research to provide important #a s of sho#in" ho# e%perience affects developin" &rains. (ie"el has sho#n ho# attuned relationships in infanc chan"e &rain structure in #a s that later affect social and emotional development.
(ie"el, D. :4++1;. 'o#ard an interpersonal neuro&iolo" of the developin" mind5 attachment relationships, 6mindsi"ht,7 and neural inte"ration. 3nfant <ental =ealth 4ournal, '', C=@FI.

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A current research stud & Casenhiser, (tie&en and (han.er at the Milton and Ethel Garris Research Institute at Kor. Nniversit is investi"atin" &ehavioral and neuroph siolo"ical outcomes of intensive DIR)Floortime, usin" &oth ERP and EEmeasurements. A preliminar report of a randomi$ed controlled trial #ith results of the first ear of a t#o ear intervention sho#s si"nificant effectiveness of the /social@ communication approach0 &ased upon the DIR)Floortime frame#or.. 'he have found si"nificant improvements in social interaction s.ills after 4 hours)#ee. of DIR &ased therap for one ear. Results of ima"in" studies are in pu&lication.
Casenhiser, D :4+11; !earnin" throu"h interaction in children #ith autism5 Preliminar data from a social@ communication@&ased intervention %utism (ept 4+11

Parent choice
Part of the definition of 6evidence &ase7 is clinical e%perience. <hile research efforts continue to e%plore the etiolo" , &iolo" , and efficac of treatment approaches for autism, clinical e%perience also continues to accumulate. DIR)Floortime pro"rams have hi"h famil satisfaction ratin"s and are #idel utili$ed as an effective frame#or. for assessment and intervention. 'he Interdisciplinar Council for Developmental and !earnin" disorders :ICD!; provides a trainin" pro"ram for clinicians and teachers to &ecome certified in usin" DIR)Floortime. 'he certification process re?uires several ears of trainin", and is desi"ned for licensed or certificated clinicians and teachers. Floortime can also &e done & parents, care"ivers, and non@certified professionals, under the "uidance of a specialist for a particular child. It is utili$ed in over B* countries around the #orld. A revie# & the 3ational Institute of Mental Gealth :3IMG; states, 6'here is no sin"le &est treatment pac.a"e for all children #ith A(D. Decisions a&out the &est treatment, or com&ination of treatments, should &e made & the parents #ith the assistance of a trusted e%pert dia"nostic team.7
3IMG. :9une 4, 4++F;. %utism -pectrum +isorders .1ervasive +evelopmental +isorders. Retrieved 9une D, 4++F, from http5))###.nimh.nih."ov)health)topics)autism@spectrum@disorders@pervasive@developmental@ disorders)inde%.shtml

Because of the #ide ran"e of individual differences in children #ith autism, and the man uni?ue relationships #ithin families, it is necessar and proper for parents to have the information and options necessar to ma.e informed choices a&out the t pe of services their child #ill receive. DIR)Floortime has a solid &ase of empirical evidence, and is #idel used for children of all a"es and a&ilities. 'he clinical evidence for functional outcomes does not clearl favor &ehavioral approaches over developmental approaches. Evidence &ased practice means the clinician can utili$e all t pes of information includin" clinical e%pertise, and a famil 0s individual values and preferences, in addition to pu&lished research. 'here is ample evidence for the effectiveness of DIR)Floortime to support an informed parent choice.

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