Young children with autistic-like behaviors or with a suspected diagnosis of autism are currently a "burning" topic in Switzerland, as in the whole world, because in recent years the numbers of such children are increasing rapidly in an alarming way.

There are also many educational and therapeutic approaches to how best to deal with these children and their behaviors. Roughly speaking, these can be divided into 3 categories:

Behavior-oriented behaviorist approacheswhose main strategy is operant conditioning to train desired adapted behavior by means of preconceived programs (e.g. ABA/Applied Behaviour Analysis).

  1. Biologically oriented measures, trying to influence the symptoms through diet, nutritional supplements and pharmacological means
  2. Relationship-oriented approachesincluding 'parent-implemented approaches', the goal of which is to address, in a non-directive and child-centered manner, the core deficits and developmental delays that underlie the symptoms.

The main difficulties of children with autism spectrum disorder (ASD) are known to be in the area of communication and relationships, e.g.

  1. create reciprocal emotional closeness
  2. Using communication and first words in a conscious and emotionally meaningful way
  3. Maintain a lasting emotional exchange
  4. lack of spontaneous exploration and creative symbol play
  5. persistent focus on details of objects as a permanent occupation
  6. often additional secondary symptoms such as perseverations, sensory regulation and processing problems, challenging or stereotyped behaviors

One would think that when a child's primary communication and relationship problems are present, relationship-oriented approaches that also involve parents and family would be obvious - no matter what the child eats, takes in supplements, or receives in behavioral training. Instead, behavioral training methods such as ABA are considered the supposedly only accepted method, although de facto

  1. the effectiveness of ABA is by no means clearly proven
  2. the child's actual relationship difficulties are not a treatment goal for ABA

 However, behavioral training has had the upper hand for years. This is because, while behavioral approaches are traditionally considered evidence-based, the fact that relationship-based approaches have also been among the established evidence-based methods for years is generally not yet known. This includes the DIRFloortime approach, which originated in the U.S. and has recently found increasing application in German-speaking countries as well, in families and institutions seeking alternatives to traditional behaviorstyle training methods.

 Early remedial education is often one of the first specialties to work with the child and family in such developmental delays, communication and behavioral difficulties, and can often even bring about augmented improvement in the problematic aspects - often long before a diagnostic process begins or a diagnosis is established.

Why is it that autistic-like behaviors can often be massively improved by remedial or similar interventions, so that sometimes a diagnosis does not even occur?

 Since the focus of modern special educators is not the disability or diagnosis, but to see the child as a whole person with all his abilities, problems and resources and in his family context with a relationship-oriented view, it is not surprising that more and more special educators are interested in the relationship-oriented DIRFloortime approach, which offers them a coherent and practically applicable theory that has been tested for almost 50 years.

The gleam in the eyes of the child

DIR refers to an individualized relationship-oriented development model (DIR = Developmental - Individual-difference - Relationship-based) with Floortime as its practical application and the goal of creating emotionally coherent exchange situations with the child and promoting or catching up on insufficiently developed functional emotional abilities. The DIRFloortime approach is a universal holistic and resource-oriented developmental model for socio-emotional development that helps us to understand and treat children with autistic-like and autistic behaviors in a new and holistic way as well. The DIR model focuses on the individuality of each child and includes parents as primary caregivers and central partners in treatment. Because when parents communicate with their child in a therapeutic way every day, everyone is helped: the child with his or her development, the parents who are concerned or distressed about this, - and the public finances.

The goals of the DIR approach are not primarily "autism-specific," but the same goals that all parents want for their child: a stronger emotional bond, joy in life, the sparkle in the child's eyes, warm relationships with others, communication through gestures and intelligible speech, involvement in meaningful activities, creative personality development. To achieve these goals, the DIRFloortime model offers differentiated strategies, techniques and activities. The goal is to use positive emotionality and regular interactive 1-1 play sessions (often, but not necessarily, on the floor) to build relationships and promote the child's holistic personality development.

Following the child's lead while helping him climb the developmental ladder

By following the child's natural emotional interests (i.e., letting him take the lead) while challenging him using emotionality and playful interaction and ongoing "communication circles," we guide the child to relate and make increasing use of his intrinsic social, emotional and intellectual capacities. This is because the human brain, that is, EVERY human brain, is designed to change and learn.

 The DIRFloortime model provides us with an extremely helpful "map" for a child's development that gives us clear direction and guidance. This developmental ladder consists of 6 functional emotional developmental levels that most children have mastered by age 4. But children with autism, autistic-like or autistic traits have difficulties and need to catch up here.

Functional Emotional Developmental Levels/ Capacities (FEDLs/ FELCs).

The healthy mental-emotional development of a child is built on

FEDL 1: Focus, share attention, self-regulate to participate in the environment with interest.

FEDL 2: Engage with others and relate to them lovingly.

FEDL 3: Initiate interaction, two-way gestural communication, imitation, imitation.

FEDL 4: Complex collaborative creative problem solving using gestural communication, first words.

FEDL 5: Symbolize what is experienced using imagination, images, and language.

FEDL 6: Building bridges between ideas, logical as well as emotional thinking, storytelling, sense of reality.

A holistic view of man

The holistic approach underlying these ideas is based on Image of man assumes universal human assets and potentials that are fundamentally human and can be developed in every person, regardless of disability, impairment, or diagnosis.

In this, relationship-oriented approaches differ fundamentally from behaviorist methods, which basically assume that autism is a physical deficit or 'innate' as a biological defect, and therapy can therefore only train more adapted behaviors and modify disturbing symptoms.

In contrast, the DIR model is based on the assumption that feelings and emotionally coherent relationships are fundamental to all subsequent developments of a child, including language, cognition, play, learning, social behavior.

Through this positive, dynamic and playful approach, we redefine autism: namely, as a developmental disorder with often good prospects for growth and positive change. Using the DIR model, which describes the child's overall mental-emotional development using Functional Emotional Developmental Levels (FEDLs), she sheds light on the mysterious symptoms. In this method, one tries to empathize with the child's world and 'pick him up' through his interests and guide him into a shared world and help him 'climb the developmental ladder'. It is about lovingly accepting the child at his or her current stage of development and fostering his or her strengths in order to help him or her master his or her weaknesses as well. This is because the ability to relate is the basic prerequisite for other cognitive, social, emotional, linguistic and motor skills as well as self-awareness to develop to their full human potential.

Evidence-based treatments for autism:

Despite hundreds of studies on the behavioral training method ABA (Applied Behavior Analysis/ Lovaas), traditionally considered the only effective evidence-based treatment method for autism, this belief is based on only 4, and in fact only 3, studies on ABA that met the criteria to be included in a recent meta-analytic publication (one of the 4 studies was a follow-up evaluation with the same data). In a recent review (2018) on evidence-based interventions for children and adolescents with autism, Dr. R. Solomon points out that the rest of all these many ABA studies are characterized by weak design and follow-up, weak methodology, too small samples, and lack of external validity. The original study on ABA by Lovaas did not meet the requirement criteria for a rigorous study and was excluded from the meta-analysis because of lack of randomization, systematic errors in group distribution and outcome values.

According to the U.S. National Academy of Sciences, there is no proven regularly successful autism treatment method and the National Institute of Mental Health (NIMH) states 'There is no single best treatment package for all children with ASD' (2009).

In various reviews of RCT (Randomised Control Trials) research on DIRFloortime, researchers are increasingly concluding that DIRFloortime and 'parent-implemented' relationship-oriented developmental approaches are among the evidence-based practice approaches. Moreover, relationship-oriented treatment approaches such as DIRFloortime improve core autism deficits, e.g., social and emotional reciprocal relationships, spontaneous initiation of conversations. In contrast, the meta-analysis found that ABA 'did not result in significant improvements in cognitive, language, or adaptive behavioral outcomes compared with normal care.'

In 3 recent studies, J. Mercer (2015), Odom et al. (2014), and Pajareya et al. (2011) found that additional 'parent-implemented' DIRFloortime interventions at home 1-2 hours/day for 4 months showed statistically significant and clinically meaningful improvements.

In all recent reviews of randomized control trials, the following methodological values (measures) of 'parent-implemented' relationship-oriented developmental models are consistently evident:

  1. They are all primarily child-centered and non-directive, without conditioning behavioral training or ready-made instructional programs
  2. Impact is operationalized as: interactive, functional, language, social developmental progress. Empirically measured, children with ASD make clinically and statistically significant progress in several measured domains
  3. Programs that provide 'intensive early intervention' with more hours/week of DIR intervention appear to be more effective than those with fewer hours. 'Intensive' = at least 10 hours/week of emotionally-involving 1-1 interaction that both enjoy. 'Early intervention' = interventions as early as possible for children with ASD (from 18 months to 6 years).
  4. Consistent outcomes of improved interactive/social skills of children with ASD; improved interactive skills of parents to relate effectively with their child; improved outcomes for development of various social, language, and developmental domains.

ABA behavioral therapy usually involves 30-40 hours/week of intensive 1-1 intervention at a cost of $30000 - 60000 per year/child. With today's diagnosis rates for autism, this is completely financially prohibitive for payers. In contrast, 'parent-implemented' relationship-oriented methods such as DIRFloortime cost only a fraction of this, at about $ 2500 per year/child, because the parents are a central part of the therapeutic offer to help their child. This in turn also helps the parents, and the whole family. And the public finances. So a relationship offer that suits everyone involved!

Bibliography:

Greenspan, Stanley (2001) My child learns differently. Walter Publishing House

Greenspan, Stanley (2009) Engaging Autism. Merloyd Lawrence Publishers

Janert, S. (2016) Building bridges for autistic children. Reinhard Publishing House

Lovaas, O.J. (1987) Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.

Mercer, J. (2015) Examining DIRFloortime as a treatment for children with autism spectrum disorders. A Review of Research and Theory. Res Soc Work Pract, 27(5), 1-11.

National Research Council (2001) Educating children with autism. National Academy Press

Pajareya et al. (2011) A pilot randomized controlled trial of DIRFloortime parent training intervention for pre-school children with autistic spectrum disorders. Autism, 15 (2), 1-15

 Solomon, Rick (2016) Autism: The Potential Within. Lulu Publishing

Solomon, Rick (2018) Commentary: Evidence-based interventions for children and adolescents with autism spectrum disorders. In: Curr Probl Pediatr Adolesc Health Care.

 Spreckley, M. et al. (2009) Efficacy of Applied Behavioural Intervention in preschool children with autism for improving cognitive, language and adaptive behaviour: a Systematic Review and Meta-analysis. The Journal of Pediatrics. 154(3): 338-344

 

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