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Relationship-Based Early Intervention Approach to Autistic Spectrum Disorders: The Developmental, Individual Difference, Relationship-Based Model (The DIR Model) 

Relationship-Based Early Intervention Approach to Autistic Spectrum Disorders: The Developmental, Individual Difference, Relationship-Based Model (The DIR Model)

Chapter:
Relationship-Based Early Intervention Approach to Autistic Spectrum Disorders: The Developmental, Individual Difference, Relationship-Based Model (The DIR Model)
Author(s):

Stanley I. Greenspan

and Serena Wieder

DOI:
10.1093/med/9780195371826.003.0068
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Key Points

  • The DIR Model (1) focuses on functional emotional capacities—joint attention, engagement, two-way communication, problem solving, and symbolic thought— which provide the foundation for development and (2) treats impeding sensory motor and regulatory challenges—auditory, visual-spatial, motor—through interactive learning relationships with parents, teachers, and therapists. These interactive experiences are believed to improve the connectivity of cortical neurons that process sensory motor information. This improvement, as a mechanism of improvement, is consistent with the current view of autism as a disorder of connectivity between different parts of the brain.

  • Central to the DIR Model is the role of the child’s natural emotions and interests. Studies have shown that they are essential for engagement and interaction between children and caregivers. These interactions improve the neural connectivity and thus enable successively higher levels of social, emotional, and intellectual capacities.

  • Deficits associated with autism stem from compromises in an infant’s ability to connect emotions (or intent) to motor planning and sequencing, to sensations, and later, to early forms of symbolic expression.

  • With caregivers’ creating states of heightened pleasurable and other affects tailored to the child’s unique motor and sensory-processing profile, the child can develop and strengthen the connection between sensation, affect, and motor action, which leads to more purposeful affective behavior. This, in turn, leads to reciprocal signaling, a sense of self, symbolic functioning, and higher-level thinking skills.

  • Clinical outcome reports have long described the benefits of DIR intervention, and new research is confirming the importance of developmental models of assessment and very early intervention, which can change the course of the disorder.

Relationship-based approaches are part of a broader category of developmental approaches that help children with autistic spectrum disorders (ASDs) and related special needs conditions. Based on a modern understanding of human development, these approaches recognize the importance of relationships; interactions with primary caregivers, therapists, and peers; and individual differences in infants’ and children’s ability to process sensations and plan actions. Developmental approaches call for early identification and early and intensive intervention.

A feature common to most developmental-relationship-based approaches is the focus on human interactions as a primary learning path. The Developmental, Individual-Difference, Relationship-Based Floortime Model (DIR Model) presented in this chapter systematizes an understanding of the child and his family and culture, including diagnostic profiles. This comprehensive framework enables clinicians, parents, and educators to construct a program tailored to the child’s unique challenges and strengths.

Central to the DIR Model is the role of the child’s natural emotions and interests. Studies have shown that they are essential for engagement and interaction between children and caregivers. These interactions improve the neural connectivity and thus enable successively higher levels of social, emotional, and intellectual capacities.

Floortime, derived from the DIR Model, is a specific intervention technique in which parents and other members of the intervention team follow the child’s natural emotional interests while challenging the child to master richer social, emotional, and intellectual capacities. Floortime emphasizes the child’s initiation, reciprocity, continuous flow of interactions, reasoning, and empathy. With young children, these playful interactions often occur on the “floor,” but they expand to include conversations and interactions in other places.

The DIR Model guides a team that often includes speech therapists, occupational therapists, educators, mental health (developmental-psychological) professionals, and, where appropriate, biomedical personnel. Parents and other family members and caregivers are vital in developmental, relationship-based approaches because of the importance of their emotional relationships with the child. This chapter will describe the DIR Model in greater detail.

The Developmental, Individual-Difference, Relationship-Based Model

The “D” of DIR: Functional Emotional Developmental Capacities

Table 60-1 lists the six Functional Emotional Developmental levels, which explain how children integrate all their capacities (motor, cognitive, language, visual-spatial, sensory) to carry out emotionally meaningful goals. The support for these levels is reviewed elsewhere (Greenspan, 1979, 1989, 1992, 1997b).

Table 60–1. The six functional emotional developmental levels

Level

Description

1. Shared attention and regulation

Attends to multisensory affective experience and, at the same time, organizes a calm, regulated state (e.g., looks at, listens to, follows the movement and voice of a caregiver, and moves purposefully).

2. Engagement and relating

Engages with caregivers and expresses affective preference and pleasure (e.g., shows joyful smiles and warm affection with a familiar caregiver). Engagement evolves to include tolerating wider ranges of emotions, such as anger, frustration, disappointment, and fairness, within the relationship.

3. Purposeful emotional interactions

Initiates and responds to two-way presymbolic gestural communication (opens and closes circles of communication, e.g., back-and-forth smiles, sounds, and gestures that build around a common theme, such as reaching for and grasping a rattle in the caregiver’s hand and then returning it when the caregiver reaches out).

4. Shared, social problem-solving (joint attention)

Organizes chains of two-way communication to solve social problems (opens and closes many circles of communication in a row); maintains communication across space; integrates affective polarities; and synthesizes an emerging prerepresentational organization of self and other (e.g., taking Dad by the hand to get a toy on the shelf). Here, aware of what he can and cannot do (self) to get the toy he wants, the child seeks the help of someone else (other). Prior to representing intent or ideas in words, the child does so through gestures and actions.

5. Creating ideas

Creates and functionally uses ideas as a basis for creative or imaginative thinking, giving meaning to symbols (e.g., engaging in pretend play, using words to meet needs, “Juice!”).

6. Building bridges between ideas (logical thinking)

Build bridges between ideas as a basis for logic, reality testing, thinking, and judgment (e.g., answer “Wh” questions, including “Why”; engage in debates opinion-oriented conversations; elaborate pretend dramas).

The “I” of DIR: Individual Differences in Sensory Modulation, Sensory Processing, Sensory Affective Processing, and Motor Planning and Sequencing

These biologically based individual differences are the result of genetic, prenatal, perinatal, and maturational variations and/or deficits. They can be characterized in at least four ways:

  1. 1. Sensory modulation, including hypo- and hyper-reactivity in each sensory modality (touch, sound, smell, vision, and movement in space).

  2. 2. Sensory processing in each sensory modality, including auditory processing and language and visual-spatial processing. Processing includes the capacity to register, decode, and comprehend sequences and abstract patterns.

  3. 3. Sensory-affective processing in each modality (e.g., the ability to process and react to affect, including the capacity to connect “intent” or affect to motor planning and sequencing, language, and symbols). This processing capacity may be especially relevant for ASD (Greenspan & Wieder, 1997, 1998).

  4. 4. Motor planning and sequencing, including the capacity to sequence actions, behaviors, and symbols, such as symbols in the form of thoughts, words, visual images, and spatial concepts.

The “R” of DIR: Relationships and Interactions

Affective interaction patterns include developmentally appropriate, or inappropriate, relationships with the caregiver, parent, and family. These interaction patterns bring the child’s biology into the larger developmental progression and can contribute to the child’s functional developmental capacities. Developmentally appropriate interactions with a child mobilize his intentions and affects and enable him both to broaden his range of experience at each level of development and to move from one functional developmental level to the next. In contrast, interactions that do not deal with the child’s functional developmental level or individual differences can undermine progress. For example, a reserved caregiver may not be able to easily engage an infant who is under-reactive and self-absorbed. A child who does not have the interactive support of a parent to explore negative emotions symbolically can have anxiety, rigidities, obsessions, and constricted affect.

The Importance of Affect

Explorations of the types of thinking that are part of skillful social interactions (i.e., emotional intelligence) and concepts of multiple intelligences have supported and increased interest in the role of emotions (Gardner, 1983; Goleman, 1995; Committee on Integrating the Science of Early Childhood Development, 2000; Kasari et al., 2006). A clinical outcome report study on DIR suggests that with an emphasis on emotional interactions, a subgroup of children diagnosed with ASDs can learn to engage with others; think creatively, logically, and reflectively; enjoy peers; and do well academically in regular classes (Greenspan & Wieder, 1998; Greenspan, 1999; Interdisciplinary Council on Developmental and Learning Disorders Clinical Practice Guidelines Workgroup, 2000).

Despite this support for and greater interest in the role of emotions in human development, there has not been sufficient understanding of how emotions and emotional interactions impact intelligence and related cognitive and language abilities as well as many complex social and self-regulation skills. There has also not been an understanding of the psychological or neurological mechanisms of action by which emotions shape these different aspects of the mind. Because of this lack of understanding, emotions have taken a back seat to cognition, language, and memory. Therefore, the question remains: What role does emotion play in the developmental steps and pathways through which such distinctly human capacities as symbol formation, language, and reflective thinking emerge in the life of each new infant and child?

The Core Psychological Deficit in Autism and the Developmental Pathways to Joint Attention, Pattern Recognition, Theory of Mind, Language, and Thinking

Suggested autism-specific developmental deficits include those in the following abilities: (1) empathy and seeing the world from another person’s perspective (Baron-Cohen, 1994); (2) higher-level abstract thinking, including making inferences (Minshew, Goldstein, & Siegel, 1997); (3) shared attention, including social referencing and problem-solving (Mundy, Sigman, & Kasari, 1990); (4) emotional reciprocity (Dawson & Galpert, 1990; Baranek, 1999); and (5) functional (pragmatic) language (Wetherby & Prizant, 1993). Neuropsychological models that have been proposed to account for the clinical features of autism further elaborate these autism-specific developmental deficits (Baron-Cohen, Leslie, & Frith, 1985; Sperry, 1985; Baron-Cohen, 1989; Frith, 1989; Bowler, 1992; Klin, Volkmar, & Sparrow, 1992; Dahlgren & Trillingsgaard, 1996; Pennington & Ozonoff, 1996; Ozonoff, 1997; Dawson et al., 1998; Greenspan, 2001). However, do deficits in these abilities actually occur downstream from other primary deficits?

Clinical work and current research (Greenspan, 2001; Greenspan & Shanker, 2004; Greenspan & Shanker, 2007; Wieder & Greenspan, 2003) suggest that the deficits described above stem from an earlier capacity that is compromised in children with ASDs. This earlier capacity is an infant’s ability to interconnect emotions or intent, motor planning and sequencing, and sensations. It evolves into early forms of symbolic expression of their intent or emotions, such as pretending to have a tea party or act mad, which later lead to more elaborate use of symbols to create ideas (Greenspan, 1979, 1989; Greenspan, 1997b). It is hypothesized that the biological differences associated with ASDs may express themselves through the derailing of this connection, leading to both the primary and secondary features of ASDs.

The Sensory-Affect-Motor Connections

In healthy development, an infant connects the sensory system to the motor system through affect (e.g., turning to look at a caregiver’s smiling face and wooing voice rather than scowling face and harsh voice). With caregivers’ creating states of heightened pleasurable and other affects tailored to the child’s unique motor and sensory-processing profile, the child can develop and strengthen the connection between sensation, affect, and motor action (e.g., simultaneously looking, listening, and moving while engaging in meaningful problem-solving interactions). This leads to more purposeful affective behavior, which, in turn, leads to reciprocal signaling, a sense of self, symbolic functioning, and higher-level thinking skills.

As the infant negotiates the first four Functional Emotional Developmental levels (see Table 60-1; shared attention and regulation, engagement, two-way communication, and shared social problem solving), she engages in progressively more complex patterns of affective signaling with caregivers (Greenspan & Shanker, 2004). These long chains of coregulated affective gesturing enable the child to recognize various patterns involved in satisfying her emotional needs. She learns, for example, how to solicit a caregiver’s assistance to obtain some out-of-reach desired object. This solicitation becomes finely tuned, back-and-forth interactions requiring joint attention (through vocalizations and facial expressions) in a coregulated solution. She learns what different gestures or facial expressions signify—the connection between certain kinds of facial expressions, tones of voice, or behavior and an individual’s mood or intentions. Recognizing when her dad is grumpy, she waits to ask for what she wants. This ability to read the patterns of others and, through recognition of one’s own patterns, form a sense of self, is the basis for what is called intention reading or theory of mind.

This ability to read patterns is also essential if a child is to have and act on expectations—to know when to expect different kinds of responses from his caregiver or to know what love, anger, respect, and shame feel like. It is equally essential if the toddler is to know how to grasp the intentions of others. Pattern recognition, intention reading, and joint attention emerge from and require mastery of the first three Functional Emotional Developmental levels, as shown in Table 60-1 (Greenspan & Shanker, 2007).

Understanding the complexity of this process has led to the early identification of challenges and to the formulation of interventions that are tailored to the child’s biological profile and vulnerabilities. This early intervention increases the likelihood that the child will achieve some relative mastery of these critical early affective transformations and of the subsequent abilities for joint attention, theory of mind, and higher levels of language and symbolic thinking. When affect is brought into the treatment of sensory motor processing challenges in language comprehension and visual-spatial knowledge, affective transformations convert labels into meanings. Thus begins the process of comprehending symbolic imagery as well as communicating thoughts and feelings, promoting more complex and abstract reasoning, shades of gray and multicausal thinking, as well as reflective capacities of self and others (Greenspan & Wieder, 1998).

Theory into Practice: DIR Assessment and Intervention Model

The theory outlined above was assessed on a representative population of more than 1,500 children whose parents were administered the Greenspan Social-Emotional Growth Chart (Greenspan, 2004). The results of this assessment suggests that mastery of the early stages of functional emotional development is necessary for children’s social referencing and joint-attention capacities (such as reciprocal, shared social problem solving) and for progression to the subsequent stages of symbol formation, pragmatic language, and higher-level thinking (including theory-of-mind capacities such as empathy) (Bayley, 2005). This data set, supportive of the DIR Model, opens the door to further research on the central nervous system and compromises in these early emotional interactions.

Many of the core elements in the DIR Model have a long tradition in early interventions, having been used in speech and language therapy, occupational therapy, visual-spatial cognitive therapy, special and early childhood education, and playful interactions with parents (which is consistent with the developmentally appropriate practice guidelines of the National Association for the Education of Young Children [NAEYC]; Bredekamp & Copple, 1997). The DIR Model contributes to these traditional practices by further defining the child’s developmental level, individual processing differences, and the need for certain types of affective interactions in terms of a comprehensive program where all the elements can work together toward common goals.

In this model, the therapeutic program should begin as early as possible so that the children can re-engage in emotional interactions that use their emerging, but not fully developing, capacities for communication (often initially with gestures rather than words). Recent improvement in early identification now makes it possible to screen and identify challenges for a child at risk for ASDs who is less than 1 year old. However, the DIR Model can be applied to any age, as it is a developmental framework useful across the lifespan.

The Functional Developmental Profile

Implementation of an appropriate assessment of all the relevant functional areas requires a number of sessions with the child and family. These sessions must begin with discussions with the caregivers and observations. The assessment process, which is described in detail elsewhere (Greenspan, 1992; Greenspan & Wieder, 1998), includes: (1) two or more 45-minute clinical observations of child–caregiver and/or clinician–child interactions; (2) developmental history and review of current functioning; (3) review of family and caregiver functioning; (4) review of standard diagnostic assessments, current programs, and patterns of interaction; (5) consultation with speech pathologists, occupational and physical therapists, educators, and mental health colleagues, including the use of structured tests on an as-needed, rather than routine, basis; and (6) biomedical evaluation (see Figure 60-1).

Figure 60–1. Outline of the DIR approach to assessment and evaluation.

Figure 60–1.
Outline of the DIR approach to assessment and evaluation.

The assessment then leads to an individualized functional profile that captures each child’s unique developmental features outlined above in the description of DIR and creates individually tailored intervention programs (i.e., tailoring the program to the child rather than fitting the child to a general program). The profile describes each of the child’s functional developmental capacities and contributing biological processing differences and environmental interactive patterns, including the different interaction patterns available to the child at home, at school, with peers, and in other settings.

The DIR Intervention Program

The DIR Model enables the formation of a comprehensive intervention program for infants, toddlers, and preschoolers with ASDs and other developmental challenges. The program helps them to re-establish the developmental sequence that went awry (with a special focus on helping them become affectively connected and intentional). The program is built on (1) determining which of the functional emotional levels described earlier have been mastered fully, partially, or not at all; (2) understanding children’s individual differences in sensory modulation, processing, and motor planning; and (3) establishing a relationship that creates interactive, affective opportunities to negotiate the partially mastered or unmastered functional emotional developmental process. Rather than focus only on isolated behaviors or skills, the DIR-based approach focuses on the more essential functional emotional developmental processes and differences that underlie particular symptoms or behaviors. The goal is to pinpoint what is compromised and construct the developmental foundations for healthy emotional, social, intellectual functioning.

The DIR-based intervention is fundamentally different from behavioral, skill-building, play therapy, or psychotherapy. The primary goal of this intervention is to enable children to form a sense of themselves as intentional, interactive individuals; to develop cognitive, language, and social capacities from this basic sense of intentionality; and to progress through the six Functional Emotional Developmental capacities.

The DIR-based Intervention Model can be conceptualized as a pyramid, with each of the components of the pyramid building on one another (see Figure 60-2).

Figure 60–2. DIR-based intervention pyramid for children with ASD.

Figure 60–2.
DIR-based intervention pyramid for children with ASD.

As shown in Figure 60-2, elements of a comprehensive program include home-based and educational elements, clinic-based therapies for both child and caregivers, as well as nutritional and biomedical components. Most children require most, if not all, of the following components for a comprehensive program as each addresses a major area requiring further development, and each component provides the countless opportunities for successful spontaneous and semi-structured interactions that have been derailed.

  • 1. Home-based, developmentally appropriate interactions and practices:

  • Spontaneous interactions (Floortime) that follow the child’s lead to focus on joint attention and engagement. The interactions eventually become a continuous flow and then advance to problem solving. The subsequent progression into creative pretend play supports mastering the full range of emotional and cognitive abilities and prepares the child for higher levels of abstract thinking. As the child gets older, Floortime becomes more reality-based conversations and reflective talktime (20- to 30-minute sessions, eight or more times a day; as children improve, they can usually engage in longer sessions).

  • Semi-structured, affect-based problem solving, such as dealing with real-life situations where the child encounters problems throughout relevant daily experiences where he or she must interact with the parent to solve (e.g., finding his favorite crackers that are in a plastic bag, finding the tub empty when asked if ready for a bath, searching for daddy who is calling from somewhere in the house, negotiating with a sibling for a toy, or working on tasks together to support reasoning, planning and sequencing, etc.). These incidental learning opportunities require back-and-forth, problem-solving discussions or nonverbal interactions that promote logical reasoning when relevant to the child’s experience or desire. If it is a problem for the child, it is affect-based. When relevant and meaningful to the child, these opportunities lead to interactions that support interconnectivity between different areas of the brain and the sequences necessary for execution.

  • Visual-spatial, motor, and sensory activities prescribed by OT, PT and visual-spatial cognitive therapists (VCTs) for 15 to 30 minutes or more, four times a day. These semi-structured activities or games may include running and changing direction, jumping, spinning, swinging, deep tactile pressure, perceptual motor challenges, including looking-and-doing games, visual-spatial movement, discrimination, visual thinking and logic games, including treasure hunts and obstacle courses. For some children, the above activities can become integrated with the pretend play of Floortime.

  • Play dates with older or younger peers who are natural play partners and will pursue and interact with the child or respond to the adult’s coaching and mediation. The number of play dates a week should match the age of the child (i.e., a 3-year-old should have three play dates a week. Later, these can expand to small groups and semi-structured activities with other children in clubs and music, art, drama, and sports activities.

  • 2. Clinic-Based Therapies

  • Speech therapy—developmentally based models or semi-structured models when indicated (e.g., the Developmental Social-Pragmatic Model [DSPM] [Gerber, 2003], the Affect-Based Language Curriculum [ABLC] [Greenspan & Lewis, 2002] and the Social Communication, Emotional Regulation and Transactional Support [SCERTS] [Prizant et al., 2003]).

  • Sensory integration and sensory motor-based occupational therapy and/or physical therapy.

  • Family consultation and counseling to help parents design and implement their comprehensive programs, support family functioning, and provide advocacy where needed.

  • 3. Educational program, daily, with parent collaboration

  • For children who can interact and imitate gestures and/or words and engage in preverbal problem solving, the program can be either an integrated inclusion program or a regular preschool program with an aide.

  • For children not yet able to engage in preverbal problem solving or imitation, a special education program where the major focus is on engagement, preverbal purposeful gestural interaction, preverbal problem solving (a continuous flow of back-and-forth communication), and movement is needed.

  • As children prepare for academic learning, some may require individualized instruction or tutoring in reading, mathematics, visual thinking, as well specific learning techniques—for example, the Lindamood-Bell Learning Process (www.lindamoodbell.com) and visual-spatial exercises from Thinking Goes to School: Piaget’s Theory in Practice (Furth & Wachs, 1975). The other considerations involve smaller class size and facilitative environments that do not overwhelm the child.

  • 4. Consideration of nutrition and diet, biomedical interventions, and, when indicated, medications that address regulation and anxiety, possible seizures, and enhance motor planning and sequencing, concentration, and learning.

  • 5. Augmentative technologies geared to improve communication, auditory and visual-spatial processing, sensory modulation, and motor planning.

DIR-based intervention is a dynamic program, and the frequency or changes in the program depend on their progress, although Floortime, and later reflective Talktime, remain constant. In some cases, therapies and other program components can be modified if a strong home program guided by the therapists is implemented. In addition, specific techniques or tools may be indicated, such as augmentative communication, assistive technology, and activities to support imitative and ritualized learning such a social games, drama, sports, etc. As the child progresses, various activities will become part of a child’s social activities, such as clubs, sports, music, and drama. During the early years, a comprehensive program of intensive intervention is very important but then can transition into more typical activities as the child progresses.

Floortime

Floortime is the most important element of this comprehensive program. Floortime refers to unstructured “play” sessions, where the child is in the lead and initiates the ideas and the adult both follows and gently challenges the child to support spontaneous, purposeful, and flowing reciprocal interactions at both pre-symbolic and symbolic levels. In addition to Floortime “play,” the Floortime principles of follow the lead, engage, challenge, and expand inform all the child’s therapies so that children are maximally interested and engaged in learning interactions.

In Floortime, the caregiver first enters into the child’s world by showing interest in the child’s activity and then engages with the child. Once the child and caregiver have established a rhythm—a back-and-forth communication (gesturally and verbally with deference to the child’s sensory profile)—the caregiver next, gently and carefully, expands on the child’s activity. The expansion occurs when the caregiver creates a challenge within the context of the child’s interest.

Floortime Example

A nonverbal and unengaged child was fixated with four crayons—touching, rolling, and lining them up. To become a partner in this activity, Mom sat next to her daughter and, following her lead, touched and rolled the crayons too, carefully and non-intrusively. After being accepted as a partner in the activity, Mom moved to the next phase—challenge and expand. Staying with the crayons because this was the child’s interest, she gently rolled the crayons into a small bag, which she then set on her head. Intrigued, the child reached up and grabbed the bag off Mom’s head. A beginning—the child related Mom to the crayons—shared attention. Mom put the bag on her head again, and the child pulled it off a second time. Some back and forth. The third and fourth times, the child smirked a little as she got the bag off Mom’s head. Now for a more complex challenge. Mom had to think about how to change the game slightly to expand the interaction without taking over and dampening the child’s engagement. Mom hid the bag in her hand and showed the child the backs of both fists. Sure enough, the child opened Mom’s hands to discover which one held the crayons. Upon finding them, she beamed with delight.

The principle is to increase the complexity of the child’s motor behavior, such as searching in Mom’s hand, while maintaining the shared attention. The same holds for increasing the complexity of the sensory input. Mom can add sound—wow’s, eee’s, woooo’s, whatever—as her child searches for the crayons in slightly more difficult places. Then the child combines emotion, shared attention, motor planning and sequencing, visual-spatial thinking, and auditory processing, all which started with the child’s fixation with four crayons and a Mom who followed the child’s lead, engaged, challenged, and expanded.

Challenges and Principles in the DIR-Based Intervention Model

The critical principle in each aspect of a comprehensive intervention program is to engage the child at his or her level and to help the child master that level and subsequent levels. Often, teams are working at multiple levels at one time. A child, for example, who has partial mastery of using ideas but is not fully engaged or interactive, still needs work at the earlier levels.

As focus and engagement are fostered, attention must be paid to the children’s profile of individual processing differences (regulatory profile), as described earlier. For example, if they are over-reactive to sound, talking to them in a loud voice may lead them to become more aimless and withdrawn. If they are over-reactive to sights, bright lights and even very animated facial expressions may be overwhelming for them. On the other hand, if they are under-reactive to sensations of sound and visual-spatial input, talking in a strong voice and using animated facial expressions in a well-lit room may help them attend. Similarly, in terms of their receptive language skills, if they are already at the point where they can decode a complex rhythm, making interesting sounds in complex patterns may be helpful. On the other hand, if they can only decode very simple, two-sequence rhythms, simpler rhythms will be better. One may find that children remain relatively better focused in motion, such as when they are being swung. Certain movement rhythms may be more effective than others.

It is especially difficult to foster a sense of intimacy. As children are encouraged to attend and engage, it is critically important to take advantage of their own natural interests. It is most helpful to follow their lead and look for opportunities for that visceral sense of pleasure and intimacy that leads them to want to relate to the human world. Intimacy is further supported as children are helped to form simple, and then more complex, gestural communications.

Illustration

A father was continually struggling to get his very withdrawn son to interact with him. When the father tried to draw him out by asking questions, the child ignored him. In a therapy session, the therapist suggested trying simple gestural interactions first.

While his son was exploring a toy car, the father put his finger on it very gently and pointed to a particular part, as though to say, “What’s that?” In touching it, the father actually moved the car so the son felt the car moving in his hands and noticed, without upset, his father’s involvement. The son pulled the car closer to him and looked at where the father had put his finger.

This more physical, gestural communication sparked at least a faint circle of communication: opening—the father’s building on the son’s interest in the car by touching a spot; closing—the son’s looking at that particular spot and pulling the car towards him.

This circle created a foundation for more complex communication. After this minimal interaction, the son began to move his car back and forth. The father got another one and started first moving it back and forth next to his son’s and then toward his son’s car but not crashing into it. The son initially pulled his car away but then engaged by moving it faster toward his father’s. A few circles were closed in a row, and real interaction was beginning.

As their gestural interaction became complex—the father hiding his son’s car and his son pointing, vocalizing, and searching for it—it fostered expanding from gestures to symbols. During this gesturing, the father started to describe his own action by saying, “fast” and “slow.” After he repeated these words several times, the boy zoomed his car past his father’s and uttered a close approximation to “fast.” The father beamed, amazed that his son could learn a new word and use it appropriately so quickly.

A major challenge is children’s tendency to perseverate. One child would only repeatedly open and close a door. Another would only bang blocks together. The key is to transform the perseveration into an interaction. Caregivers can use children’s intense motivation to their advantage to get gestural circles of communication opened and closed. For example, they can get stuck in a door or have their hands caught between some blocks. They can be gentle and playful as the child tries to get them out of the way (like a cat-and-mouse game). As gestural interactions occur, behavior becomes purposeful and affective. When doing “playful obstructions,” “fencing in,” or “playing dumb,” they can modulate child’s feelings of annoyance and can help soothe and comfort as well use affect cues and joint problem solving to “help,” although often children find “playful obstruction” amusing.

As children become more purposeful and guided by their own initiation and intent, they can imitate gestures and sounds more readily and start simple but emotionally meaningful symbolic actions such as feeding a doll or kissing a bear. With continuing challenges to be intentional, they copy complex patterns and imitate sounds and words, often gradually beginning to use words and “pretend” on their own.

As one moves toward more representational or symbolic elaboration, it can be challenging to help children differentiate their experiences. They need to learn cause-and-effect communication at the level of ideas and to make connections between various representations or ideas. Caregivers become the representation for reality and the ability of clinicians or parents to enter the symbolic world of children and become “players” becomes the critical vehicle for fostering emotional differentiation and higher levels of abstract and logical thinking.

Relating to children when they are feeling strong affects is critical. They are connecting words to underlying affects that give them purpose and meaning. When children are motivated—for example, in trying to negotiate to get a certain kind of food or to go outside—there is often an opportunity to open and close many symbolic circles. The child who tries to open the door to go outside and is angry that he cannot may, in the midst of feeling annoyed, open and close 20 circles of communication if the adult soothingly tries to find out what he wants to do outside.

Children with ASDs find it especially difficult to shift from concrete to abstract modes of thinking because they do not easily generalize from a specific experience to other similar experiences. There is a temptation to teach them answers and repeat the same question by scripting the dialogue or providing scaffolding so they might guess and fill in the blank. However, they can only learn to abstract and generalize through active, emotionally meaningful experiences that help them connect affects or desires to reasoning and actions. Long conversations with debates are most helpful as it helps the child express his or her own opinions and the reasons for them (e.g., “I like juice because it tastes good”) rather than memorized elaborations of rote facts (e.g., “The juice is orange”) (Greenspan & Wieder, 1997).

As children develop, becoming symbolic and abstract is most often derailed by anxiety, which occurs secondary to poor language and visual-spatial processing. The child who may already have words to express what he wants and even why may not adequately understand what someone else is saying and may become anxious about feelings and ideas outside his comfort zone. Sometimes the child tries to respond, but his comments become tangential, associative, or off topic and the conversation becomes fragmented. Poor visual-spatial knowledge also derails the child’s making sense of what he sees and knowing where he is in space. Without these abilities, he cannot respond purposefully to situations at hand. When both language and visual-spatial weaknesses interact, the child may appear distracted, inattentive, and/or illogical. Children who get stuck at concrete levels of language and thought derive security from what they see. Dependent on visual anchors and rituals, they have difficulty developing flexibility and logical abstracting abilities.

Summary

In summary, as the child progresses through the Functional Emotional Developmental levels of regulation and joint attention, engagement, two-way communication, shared social problem solving, creating ideas, and logical thinking (see Table 60-1), the therapeutic program works on mobilizing all levels at the same time in each and every interaction. The therapeutic program often evolves to a point where the child and family are involved in three types of activities: (1) spontaneous, creative interactions (Floortime); (2) semi-structured, problem-solving interactions to learn new skills, concepts, and master academic work (e.g., creating problems to solve, like negotiating for cookies or mastering spatial concepts, such as “behind” and “next to,” by discovering where the favorite toy is located); and (3) motor, sensory, language, and visual-spatial play to strengthen fundamental processing skills. It is important to note that the DIR Model and intervention program apply as children get older when the different dimensions of development continue to be uneven and/or when the focus needs to shift to emotional development, learning challenges, and anxiety and mood regulation. The DIR Model can guide the intervention of each child and family and his or her unique profile as development unfolds across the lifespan.

Selected Research and Outcome Studies on the DIR-Floortime Model

In the following section, we briefly review selected studies relevant to the DIR approach. Built on years of research in developmental psychology (Greenspan & Wieder, 1998; Greenspan & Shanker, 2004) that underscores the importance of early relationships and family functioning (Greenspan, 1992), the DIR Model also integrates research contributions from various disciplines, such as speech and language pathology (Tannock, Girolametto, & Siegal, 1992; Wetherby & Prizant, 1995; Gerber & Prizant, 2000), occupational therapy (Ayres, 1979; Williamson & Anzalone, 1997; Case-Smith & Miller, 1999), and social work (Shahmoon-Shanok, 2000). Neuroscience research lends further support to developmental interventions (Mundy, Sigman, & Kasari, 1990; Minshew & Goldstein, 2000).

Centers for Disease Control and Prevention

A survey conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention of over 15,000 families nationwide included emotional variables from the DIR Functional Emotional Developmental Levels. This survey identified 30% more infants and children at risk (most of whom were not receiving services) than prior health surveys (Simpson, Colpe, & Greenspan, 2003).

National Research Council

Importantly, the National Research Council of the National Academy of Sciences, in their 2001 landmark report, Educating Children with Autism (Committee on Educational Interventions for Children with Autism, 2001), called for tailoring the treatment approach to unique features of the individual child and recommended to give priority to interventions that promote functional, spontaneous communication.

200 Case Chart Reviews

The first study to show initial evidence for the DIR Model was published in 1997 (Greenspan & Wieder, 1997). Greenspan and Wieder reviewed charts of 200 children who were diagnosed with ASDs and who were part of a cohort of children seen by the authors over a period of 8 years. All children met the criteria of autism or pervasive developmental disorder not otherwise specified (PDD-NOS) as described in DSM-III-R and DSM-IV, and scored in the autism range on the Childhood Autism Rating Scale (Western Psychology Services, 1988). All 200 cases received a comprehensive relationship and developmentally based intervention program for at least 2 years, under the supervision of Dr. Stanley Greenspan and/or Dr. Serena Wieder. The children ranged in age from 22 months to 4 years, with the majority between 2.5 and 3.5 at the initial evaluation. The goal of the review was to reveal patterns in presenting symptoms, underlying processing difficulties, early development, and response to intervention to generate hypotheses for future studies.

The study identified sensory processing and modulation difficulties in all the children, and the authors hypothesized that different underlying processing patterns seemed to include a difficulty in connecting affect and sequencing capacities and could be a possible common denominator, suggesting that difficulties with relating and intimacy are often secondary to underlying processing disturbances. (See Table 60-2.) They also suggested that the difficulty in engaging in complex purposeful gestural communication could be an early marker and that contrary to traditional beliefs, a significant number of children may have relatively better functioning in the first year with a regression in the second and third years when these more complex skills are required for social interaction.

Table 60–2. Presenting conditions of 200 cases of children with autistic spectrum disorders

Functional Developmental Component

Patients with Mild-to-Severe Impairment

Description of Functional Developmental Component

Presenting functional, emotional, developmental level

24%

Partially engaged and purposeful with limited use of symbols (ideas)

40%

Partially engaged with limited complex problem-solving interactive sequences (half of this group evidenced only simple purposeful behavior)

31%

Partially engaged with only fleeting purposeful behavior

5%

No affective engagement

Sensory modulation

19%

Over-reactive to sensation

39%

Under-reactive to sensation (with 11% craving sensation)

36%

Mixed reactivity to sensation

6%

Not classified

Motor planning dysfunction

52%

Mild-to-moderate motor planning dysfunction

48%

Severe motor planning dysfunction

Low muscle tone

17%

Motor planning dysfunction with significant degree of low muscle tone

Visual-spatial processing dysfunction

22%

Relative strength (e.g., can find toys, good sense of direction)

36%

Moderate impairment

42%

Moderate-to-severe impairment

Auditory processing and language

45%

Mild-to-moderate impairment with intermittent abilities to imitate sounds and words or use selected words

55%

Moderate-to-severe impairment with no ability to imitate or use words

According to the authors, the chart review suggested that a number of children with ASDs are, with an appropriate intervention program, capable of empathy, affective reciprocity, creative thinking, and healthy peer relationships. The authors also concluded that focusing on individual differences, developmental level, and affective interaction could be especially promising.

Greenspan and Wieder described that after 2 years of intervention, 58% of treated children no longer met the criteria for ASDs. They became warm and interactive, relating joyfully with appropriate, reciprocal preverbal gestures; could engage in lengthy, well-organized, and purposeful social problem-solving and share attention on various social, cognitive, or motor-based tasks; used symbols and words creatively and logically, based on their intent and desires, rather than using rote sequences; and progressed to higher levels of thinking, including making inferences and experiencing empathy. Some children in this group developed precocious academic abilities two or three grade levels above their ages. They all mastered basic capacities such as reality testing, impulse control, organization of thoughts and emotions, differentiated sense of self, and ability to experience a range of emotions, thoughts, and concerns. Finally, they no longer showed symptoms such as self-absorption, avoidance, self-stimulation, or perseveration. On the Childhood Autism Rating Scale (CARS), they shifted into the non-autistic range, although some still evidenced auditory or visual-spatial difficulties (which were improving), and most had some degree of fine or gross motor planning challenges.

Furthermore, children who made progress tended to improve in a certain sequence. First, within several months, they began showing more emotion and pleasure in relating to others. Contrary to the stereotypes of autism, they seemed eager for emotional contact. The problem was that they had trouble figuring out how to achieve it. They seemed grateful when their parents helped them express their desire for interaction. After parents learned to draw them out by various Floortime approaches, even children who had been very avoidant and self-absorbed began seeking out their parents for relatedness.

In 2005, Greenspan and Wieder published a 10- to 15-year follow-up study (since the start of treatment) of 16 children diagnosed with ASDs that were part of the first 200 case series and were part of the 58% of children who showed great improvements (Greenspan & Wieder, 2005). The children were all boys and ranged in age between 12 and 17 years, with a mean of 13.9 years. All these children had received a comprehensive relationship and developmentally based intervention program, including Floortime at home and DIR consultation, for at least 2 years (maximum 5), between ages 2 and 8.5 years. The authors described that after 10 to 15 years since receiving the intervention, these children became empathetic, creative, and reflective adolescents, with healthy peer relationships and solid academic skills. Based on these findings, the authors suggested that some children with ASDs can master the core deficits and reach levels of development formerly thought unattainable.

Social-Emotional Growth Chart

The DIR Model also served as the theoretical framework to develop the Greenspan Social-Emotional Growth Chart (SEGC) (Greenspan, 2004). This norm-referenced surveillance and screening of key social-emotional milestones in infants and children from birth to age 42 months is now part of the new Bayley Scales Kit of Infant and Early Childhood Development. Published by PsychCorp, the SEGC was field-tested on a representative sample of 1,500 infants and young children, and it is now offered as a surveillance and screening instrument for ASDs, with a sensitivity of 87% and specificity of 90%.

The P.L.A.Y. Project

In 2007, Dr. Richard Solomon and colleagues published an evaluation of The PLAY Project Home Consultation (PPHC), a widely disseminated program that trains parents of children with ASDs in the DIR Model (Solomon et al., 2007). Sixty-eight children from age 2 to 6 years (average 3.7 years) completed an 8- to 12-month program where parents were encouraged to deliver 15 hours per week of 1:1 interaction. Pre/post ratings of videotapes by blind raters using the Functional Emotional Assessment Scale (FEAS) showed significant increases (p ≤ 0.0001) in child subscale scores. That is, 45.5% of children made good to very good functional developmental progress. Overall parents’ satisfaction with PPHC was 90%. Average cost of intervention was $2,500/year. Despite some limitations, the pilot study of The PLAY Project Home suggests that the model has potential to both enhance developmental progress of young children with autism and to be a cost-effective intervention. The PLAY model has evolved from a small, university-based, clinical program into a low-cost train-the-trainer model that has the capacity to be disseminated nationally. 1Dr. Solomon is now conducting an NIMH-funded randomized, controlled, community-based clinical trial of the PLAY Project (Phase II SBIR grant), including 3-to 5-year-old children with ASD.

Related Research

A recent article published by Zwaigenbaum and colleagues highlights the challenges related to early detection, diagnosis, and treatment of ASDs in very young children (Zwaigenbaum, et al., 2009). The authors outline the principles of effective intervention for infants and toddlers with suspected or confirmed diagnosis of ASDs, including responsive and sensitive caretaking, enriched language environments using responsive rather than directive interaction styles, environments that provide opportunities for toddlers to take initiative in their learning, and interventions that are individualized and targeted to specific skills. Furthermore, the authors underscore that existing programs for older children “cannot simply be extrapolated” to younger children.

In addition, other developmental relationship-based approaches have shown to have positive effects, including the work of Gerald Mahoney, Ph.D., and Frida Perales, M.Ed. (Mahoney & Perales, 2005), and Sally Rogers (The University of Colorado model) (Rogers & DiLalla, 1991; Rogers et al., 2000).

In 2010, Dawson, Rogers, and colleagues reported the results of a randomized controlled trial of a comprehensive developmental behavioral intervention for improving outcomes of toddlers (18–30 months) with ASDs using the Early Start Denver Model in a 2-year program (Dawson et al., 2010). They found significant improvement in IQ, adaptive behavior, and change in the autism diagnosis. Their cohort maintained growth in adaptive behavior compared with a normative sample reflecting the benefits of early intervention. Adaptive behaviors are most reflective of the benefits of the developmentally based interventions.

Conclusion

This chapter presents a brief overview of the DIR Model and discusses its implications for assessment, intervention, and understanding the developmental pathways leading to ASDs. It also presents studies that support the DIR Model and other related research findings. A developmental, relationship-based approach can change not only the way we think about developmental disabilities, including ASDs, but what is included in the research base to improve assessment and interventions. At this time the field is expanding, beginning to go beyond reporting outcomes according to IQ scores and educational placement. But it still needs research standards for studying developmental models that are defined by the relevant areas of developmental functioning as described here and the primary goals for each child and family.

Future Directions

  • Research that captures the complexity of developmental disorders and differentiates the interventions and outcomes of children with different profiles.

  • Integrated educational models that utilize affect-based developmental curricula to make learning experiences meaningful and build the foundations for higher level emotional and cognitive functioning, including ongoing training of those working in school settings.

  • Long-term outcome studies that focus on the critical junctures of development for different subtypes along the autism spectrum and identify the opportunities and ongoing processing interventions that will support continued development.

  • Long-term studies of parent and sibling experiences and their relationships with children on the autism spectrum.

  • Expansion of social and community relationship models in various childhood settings, which extend into adulthood and identify the variables and interventions which provide continuity.

Suggested Readings

Greenspan, S. I., & Shanker, S. G. (2004). The first idea: How symbols, language and intelligence evolved in early primates and humans. Reading, MA: Perseus Books.

Cordero, J., Greenspan, S. I., Bauman, M., Brazelton, T. B., Dawson, G., Dunbar, B., et al. (2007). cdc/ICDL Collaboration report on a framework for early identification and preventive intervention of emotional and developmental challenges. Bethesda, MD: ICDL.

Solomon, R., Necheles, J., Ferch, C., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation program. Autism 11 (3), 205–224.

References

Achenbach, T. M. (1991). Integrative guide to the 1991 CBCL/4-18, YSR, and TRF profiles. Burlington, VT: University of Vermont; Department of Psychiatry.Find this resource:

    Ayres, J. (1979). Sensory integration and the child. Los Angeles, CA: Western Psychological Services.Find this resource:

      Baranek, G. T. (1999). Autism during infancy: A retrospective video analysis of sensory-motor and social behaviors at 9–12 months of age. Journal of Autism and Developmental Disorders, 29, 213–224.Find this resource:

      Baron-Cohen, S. (1989). The theory of mind hypothesis of autism: a reply to Boucher. The British Journal of Disorders of Communication, 24, 199–200.Find this resource:

      Baron-Cohen, S. (1994). Mindblindness: An essay on autism and theories of mind. Cambridge, MA: MIT Press.Find this resource:

        Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a “theory of mind”? Cognition, 21, 37–46.Find this resource:

        Bayley, N. (2005). Bayley scales of infant and toddler development, third edition (Bayley-III). Bulverde, TX: Psychological Corp.Find this resource:

          Bowler, D. M. (1992). Theory of mind in Asperger’s syndrome. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 33, 877–893.Find this resource:

          Bredekamp, S., & Copple, C. (1997). Developmentally appropriate practices in early childhood programs. Washington, DC: National Association for the Education of Young Children (NAEYC).Find this resource:

            Case-Smith, J., & Miller, H. (1999). Occupational therapy with children with pervasive developmental disorders. American Journal of Occupational Therapy, 53, 506–513.Find this resource:

            Committee on Educational Interventions for Children with Autism, National Research Council (2001). C. Lord & J. McGee (Eds.). Educating children with autism. Washington, DC: National Academy Press.Find this resource:

              Committee on Integrating the Science of Early Childhood Development, National Research Council (2000). From neurons to neighborhoods: The science of early childhood development. J. Shonkoff & D. Phillips (Eds.). Washington, DC: National Academy Press.Find this resource:

                Dahlgren, S., & Trillingsgaard, A. (1996). Theory of mind in non-retarded children with autism and Asperger’s syndrome: a research note. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 37, 759–763.Find this resource:

                Dawson, G., & Galpert, I. (1990). Mother’s use of imitative play for facilitating social responsiveness and toy play in young autistic children. Developmental Psychopathology, 2, 151–162.Find this resource:

                Dawson, G., Meltzoff, A., Osterling, J., & Rinaldi, J. (1998). Neuropsychological correlates of early symptoms of autism. Child Development, 69, 1276–1285.Find this resource:

                Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125, e17–e23.Find this resource:

                Frith, U. (1989). Autism: Explaining the enigma. London: Blackwell.Find this resource:

                  Furth, G., & Wachs, H. (1975). Thinking goes to school: Piaget’s theory in practice. New York: Oxford University Press.Find this resource:

                    Gardner, H. (1983). Frames of mind: The theory of multiple intelligences. New York: Basic.Find this resource:

                      Gerber, S., & Prizant, B. (2000). Speech, Language and Communication Assessment and Intervention for Children. In ICDL clinical practice guidelines: Redefining the standards of care for infants, children, and families with special needs. Bethesda, MD: The Interdisciplinary Council on developmental and Learning Disorders.Find this resource:

                        Gerber, S. (2003). A developmental perspective on language assessment and intervention for children on the autistic spectrum. Top Lang Disorders, 23, 74–94.Find this resource:

                        Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ. New York: Bantam.Find this resource:

                          Greenspan, S. (2001). The affect diathesis hypothesis: The role of emotions in the core deficit in autism and the development of intelligence and social skills. J Dev Learning Disord, 5, 1–45.Find this resource:

                            Greenspan, S. (2004). Greenspan Social-Emotional Growth Chart. Bulverde, TX: The Psychological Corporation.Find this resource:

                              Greenspan, S. (1979). Intelligence and adaptation: An integration of psychoanalytic and Piagetian developmental psychology. Psychological Issues. Monograph No. 4748. New York: International Universities Press.Find this resource:

                                Greenspan, S. (1989). The development of the ego: Implications for personality theory, psychopathology, and the psychotherapeutic process. New York: International Universities Press.Find this resource:

                                  Greenspan, S. (1992). Infancy and early childhood: The practice of clinical assessment and intervention with emotional and developmental challenges. Madison, CT: International Universities Press.Find this resource:

                                    Greenspan, S. (1997a). Developmentally based psychotherapy. Madison, CT: International Universities Press.Find this resource:

                                      Greenspan, S. (1997b). The growth of the mind and the endangered origins of intelligence. Reading, MA: Addison Wesley Longman.Find this resource:

                                        Greenspan, S. (1999). Building healthy minds: The six experiences that create intelligence and emotional growth in babies and young children. Cambridge, MA: Perseus Books.Find this resource:

                                          Greenspan, S. (2004). The Greenspan Social Emotional Growth Chart: A screening questionnaire for infants and young children. PsychCorp (Hartcourt Assessment).Find this resource:

                                            Greenspan S., DeGangi, G., & Wieder, S. (2001). The functional emotional assessment scale (FEAS) for infancy and early childhood: Clinical and research applications. Bethesda, MD: Interdisciplinary Council on Developmental and Learning Disorders.Find this resource:

                                              Greenspan, S., & Lewis, D. (2002). The affect-based language curriculum: An intensive program for families, therapists and teachers. Bethesda, MD: The Interdisciplinary Council on Developmental and Learning Disorders.Find this resource:

                                                Greenspan, S., & Shanker S. (2004). The first idea: How symbols, language and intelligence evolved from our primate ancestors to modern humans. Reading, MA: Perseus Books.Find this resource:

                                                  Greenspan, S., & 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.Find this resource:

                                                    Greenspan, S., & Wieder, S. (1998). The child with special needs: Encouraging intellectual and emotional growth. Reading, MA: Perseus Books.Find this resource:

                                                      Greenspan, S., & 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. Journal of Developmental and Learning Disorders, 9, 39–61.Find this resource:

                                                        Greenspan, S., & Wieder, S. (2006). Engaging autism: The Floortime approach to helping children relate, communicate, and think. Cambridge, MA: DaCapo Press/Perseus Books.Find this resource:

                                                          Interdisciplinary Council on Developmental and Learning Disorders Clinical Practice Guidelines Workgroup, SIGC (2000). Clinical practice guidelines: Redefining the standards of care for infants, children, and families with special needs. Bethesda, MD: Interdisciplinary Council on Developmental and Learning Disorders.Find this resource:

                                                            Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children with autism: A randomized controlled intervention study. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 47, 611–620.Find this resource:

                                                            Klin, A., Volkmar, F., & Sparrow, S. (1992). Autistic social dysfunction: Some limitations of the theory of mind hypothesis. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 33, 861–876.Find this resource:

                                                            Mahoney, G., & Perales, F (2005). Relationship-focused early intervention with children with pervasive developmental disorders and other disabilities: A comparative study. Journal of Developmental and Behavioral Pediatrics, 26, 77–85.Find this resource:

                                                            McGee, G., Krantz, P., & McClannahan, L. (1985). The facilitative effects of incidental teaching on preposition use by autistic children. Journal of Applied Behavior Analysis, 18, 17–31.Find this resource:

                                                            Minshew, N., & Goldstein, G. (2000). Autism as a disorder of complex information processing. In ICDL clinical practice guidelines: Redefining the standards of care for infants, children, and families with special needs. Bethesda, MD: The Interdisciplinary Council on developmental and Learning Disorders.Find this resource:

                                                              Minshew, N., Goldstein, D., & Siegel, D. (1997). Neuropsychologic functioning in autism: Profile of a complex information processing disorder. Journal of the International Neuropsychological Society, 3, 303–316.Find this resource:

                                                              Mundy, 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.Find this resource:

                                                              Ozonoff, S. (1997). Causal mechanisms of autism: Unifying perspectives from an information-processing framework. In D. Cohen & F. Volkmar (Eds.), Handbook of autism and pervasive developmental disorders (pp. 868–879). New York: John Wiley.Find this resource:

                                                                Pennington, J., & Ozonoff, S. (1996). Executive functions and developmental psychopathology. Journal of the International Neuropsychological Society, 37, 51–87.Find this resource:

                                                                Prizant, B., Wetherby, A., Rubin, E., & Laurent, A. (2003). The SCERTS Model: A transactional, family-centered approach to enhancing communication and socio-emotional abilities of children with autism spectrum disorder. Infants, Young Children, 16, 296–316.Find this resource:

                                                                Rogers, S., & DiLalla, D. (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.Find this resource:

                                                                Rogers, S., Hall, T., Osaki, D., Reaven, J., & Herbison, J. (2000). The Denver model: A comprehensive, integrated educational approach to young children with autism and their families. In J. Handleman & S. Harris (Eds.), Preschool education programs for children with autism (2nd Ed) (pp. 95–133). Austin, TX: Pro-Ed.Find this resource:

                                                                  Shahmoon-Shanok, R. (2000). The action is in the interaction: Clinical practice guidelines for work with parents of children with developmental disorders. In ICDL clinical practice guidelines: Redefining the standards of care for infants, children, and families with special needs. Bethesda, MD: The Interdisciplinary Council on developmental and Learning Disorders.Find this resource:

                                                                    Shanker, S., & Greenspan, S. (2007). The developmental pathways leading to pattern-recognition, joint attention, language and cognition. New Ideas in Psychology, 25, 128–142.Find this resource:

                                                                    Simpson, G., Colpe, L., & Greenspan, S. (2003). Measuring functional developmental delay in infants and young children: Prevalence rates from the NHIS-D. Paediatric and Perinatal Epidemiology, 17, 68–80.Find this resource:

                                                                    Solomon, R., Necheles, J., Ferch, D., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation model. Autism: The International Journal of Research and Practice, 11, 205–224.Find this resource:

                                                                    Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland Adaptive Behavior Scales. American Guidance Service.Find this resource:

                                                                      Sperry, R. (1985). Consciousness, personal identity, and the divided brain. In F. Benson & E. Zaidel (Eds.), The Dual Brain (pp. 11–27). New York: Guilford.Find this resource:

                                                                        Tannock, R., Girolametto, L., & Siegal, L. (1992). Language intervention with children who have developmental delays: Effects of an interactive approach. American Journal of Mental Retardation, 97, 145–160.Find this resource:

                                                                        Wieder, S., & Greenspan, S. (2003). Climbing the symbolic ladder in the DIR model through floortime/interactive play. Autism, 7, 425–436.Find this resource:

                                                                        Western Psychology Services (1988). Childhood Autism Rating Scale (CARS). Los Angeles, CA.Find this resource:

                                                                          Wetherby, A., & Prizant, B. (1993). Profiling communication and symbolic abilities in young children. Journal of Childhood Common Disorder, 15, 23–32.Find this resource:

                                                                          Wetherby, A., & Prizant, B. (1995). Facilitating language and communication in autism: Assessment and intervention guidelines. In D. Berkell (Ed.), Autism: Identification, education, and treatment (pp. 107–133). Hillsdale, NJ: Erlbaum.Find this resource:

                                                                            Williamson, G., & Anzalone, M. (1997). Sensory integration: A key component of the evaluation and treatment of young children with severe difficulties in relating and communicating. Zero to Three, 17, 29–36.Find this resource:

                                                                              Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., Carter, A., Carver, L., et al. (2009). Clinical assessment and management of toddlers with suspected autism spectrum disorder: Insights from studies of high-risk infants. Pediatrics, 123, 1383–1391.Find this resource: