Comprehensive Developmental based approaches such as DIR/Floortime are strongly grounded in infant and early childhood mental health, clinical and developmental psychology and the neurosciences. They are peer reviewed evidenced based Developmental neuroscientific approaches to treat children and older with autism spectrum disorder and other biopsychosocial based challenges. Below are several resources that validate a comprehensive DIR/Floortime developmental based approach to treat children with ASD and other biopsychosocial based challenges and the neuroscientific foundations that justify its use as a primary intervention approach with children and families.
In 2011 preliminary results from a fully randomized control trial of 51 children with mild to severe autism, ages 2 years 0 months to 4 years 11 months, were published by the MEHRI Foundation at York University, Canada. Participants were assigned to either a target treatment group (DIR Floortime, 25 children) or community treatment group (26 children, 16 received ABA). The study evaluated a social-communication based approach to autism. PET scans of all children were taken prior to trial start and post trial to record any neuronal changes. What was quite remarkably demonstrated were clinically significant and clinically meaningful structural neuronal changes in formerly underactive and overactive areas of brain functioning demonstrated among participants in the targeted treatment vs. control group.
Data sets among participants in the targeted DIR/Floortime treatment group (one child here presented in video below) revealed significant increased activity in the prefrontal cortex area (e.g., executive functioning responsible for emotional regulation, ideation, motor planning and sequencing); significantly reduced activity in subcortical areas (e.g., reduced size and activity of the amygdala and over activation of the hypothalamus, pituitary and adrenal axis responsible for All or Nothing responses); increased activity and functioning in FFA (fusiform face area of the fusiform gyrus) responsible for reading and processing the emotional-facial expressions of others. New areas of brain functioning were consistent with what we see with typical healthy developing children. The above prefrontal and subcortical changes were directly correlated with specific milestone increases in simple to complex circles of increasingly continuous and reciprocal social-emotional child/parent interactions and were demonstrated in the targeted treatment group vs. the community group. Re-analysis of trial result data in 2015 further revealed that the targeted treatment group considerably outperformed the community group on number of utterances produced and various speech act categories.
The published preliminary and follow up data on the 2011 MEHRI Foundation study (cited above) as well as separately other previous and current controlled randomized trials supporting a comprehensive developmental based approach, such as DIR/Floortime as a primary treatment methodology for young children and older diagnosed with ASD can be found at http://www.icdl.com/research
The following is a one hour and forty minute talk with video presentation given by one the most experienced, internationally renown DIR/Floortime Occupational therapist,, Rosemary White., OTR/L. This talk and video presentation is extraordinary useful for both families and clinicians as Rosemary explains in a remarkably detailed and nuanced perspective the theory of DIR/Floortime methodology in everyday practice.
The following white paper by Diane Cullinane, M.D. is an overview of the scientific evidentiary support for the DIR/Floortime methodology to treat infants, toddlers and older with ASD and related affect-sensory and social pragmatic communication based challenges:
http://www.adaptmanitoba.ca/wp-content/uploads/2014/04/Evidence_Base_for_DIR-2014.pdf Updated, July 2017: https://docs.google.com/a/icdl.com/viewer?a=v&pid=sites&srcid=aWNkbC5jb218aWNkbHxneDozNzJiNGQxYzQyMWEzZTIx
Below are the Clinical Practice Guidelines of the Interdisciplinary Council Developmental Learning (ICDL) published in 2001. It is a comprehensive overarching view of the biopsychosocial components that form the neuroscientific foundations for a comprehensive Developmental assessment and treatment approach for individuals diagnosed with autism spectrum and other biopsychosocial challenges. The chief editor is the late Dr. Stanley Greenspan, M.D. (former head of NIMH, Mental Health Study Center and the Clinical Infant Development; co-founder of Interdisciplinary Council Developmental Learning and the DIR/Floortime methodology). It is co-authored by many of the foremost professionals within the biopsychosocial sciences.
Now, it is extremely valuable for all primary caregivers and clinicians working with infants, toddlers, older children and adults with ASD to begin to read the voluminous evidenced-based research that supports not the older traditional and essentially simplistic surface behavioral based models (ABA) but rather comprehensive evidenced-based Developmental social pragmatic approaches (DSP) such as DIR/ Floortime . The latter addresses not selectively targeted or circumscribed behaviors but rather the primary core Functional Emotional relational Developmental challenges associated with ASD. Unlike traditional applied behavioral based models, DSP approaches neither render nor conflate a false evidentiary equivalence between the biopsychosocial complexity of each child's core Functional-Emotional Developmental capacities and individual sensory-affect-motor processing differences with each child successfully trained to execute selectively targeted academic or behavioral performance tasks (i.e., the ability for each child to produce from memory on adult command or cue a set of functionally-scripted responses or what colleagues and I refer to as "surface trained behaviors", which despite cause for great concern have never been the source of the primary challenges).
Instead, Developmental social pragmatic approaches such as DIR/Floortime focus on the underlying core biopsychosocial foundations which form and maintain healthy biopsychosocial relationships. What has been clearly demonstrated over the last twenty five years in Developmental Affect Neuroscience through anatomical research and neuroimaging not just on the prenatal, infant and toddler brain but beginning in utero between two brains, specifically, the mother’s right orbital frontal cortex and limbic, hypothalamus, pituitary and adrenal axis to the prenatal, infant and toddler’s right hemisphere is how the growth and maturation of limbic to prefrontal neuronal connections in the child’s brain is critically dependent upon specific healthy dyadic emotional interactions. Beginning in infancy, this includes the Developmental biopsychosocial processes of infant/toddler/primary caregiver reciprocal emotional deepening attachment and attunement; social-emotional co-thinking and co-communicating .
Therefore, it is natural that these Developmental social pragmatic intervention evidenced grounded approaches with typical and non-typical children are entirely centered around the integration of the child's subcortical with cortical functioning (e.g., child's emerging "sense of self with others" guided by the child's affective individual sensory processing differences and addressed in the context of child/primary caregiver relationships). It is not the isolation or an inventory checklist of the child's "targeted behaviors", which are then passed off as “academic markers” but rather guiding primary caregivers to use their natural emotional intelligence to learn how to slow down and emotionally connect and engage with their child's constitutional developmental and sensory-affect-motor processing challenges that significantly enables the strengthening of these underlying neuronal pathways that lead toward the formation of new synaptic connections and meaningful Developmental milestone advance.
The justification for an evidenced based developmental social-emotional based approach garnered new appreciation by the tremendous advances made in the fields of neuroendocrinology and neuroanatomy during the mid 1990's. At this point in time there was conceptualized a radically new understanding of a non-bifurcated autonomic nervous system that is socially-emotionally co-regulated and hierarchically structured-for purposes of homeostasis or under conditions of threat recruited to fight, flight, freeze or feint responses by three distinct pathways of the unmyelineated and myelineated vagus nerve (i.e., sub-diaphragmatic, diaphragmatic and supra-diaphragmatic). The more advanced myelineated vagus nerve pathway beginning with mammals is directly connected from the basal ganglia to the striated facial muscles, ocular muscles, auditory system/middle ear and the pharyngeal and laryngeal muscles and represents a new understanding of the biopsychosocial foundations that constitute early mammal to human primate social-emotional engagement-and-autonomic regulation.
A new understanding of this phylogenetically distinct myelinated vagus pathway in humans had provided for the first time a biopsychosocial understanding of the pivotal evolutionary role that the social-emotional engagement system (the higher myelinated aspects of the vagus nerve) directly has in down regulating sympathetic flight, fight, freeze or feint responses and the reduction of negative stress hormones, such as cortisol and an increase in positive hormones, such as dopamine and oxytocin connected with the limbic hypothalamus, pituitary adrenal axis.
For example, pleasurable back and forth co-regulated/regulated child/primary caregiver face to face engagement; auditory-prosodic, tactile-gestural secure based attachment and attunement that results in critical homeostasis (e.g., up-regulation of joy, calm and restoration) or conversely, fight/ flight freeze or feint responses due to trauma ( e.g., insecure and avoidant attachment or abuse and neglect or in non-typical biological development, such as prenatal and postnatal immune-endocrine based exposures, as in ASD, a separate set of constitutional factors). In both typical and non-typical development both entail similar trajectories with respect to vagus auditory attunement or auditory shut down; functional-emotional expressive use of bodily gestural reciprocity and the affective regulation of the laryngeal and pharyngeal muscles required for vocalization, that is, the prosodic elements of speech which comprise 93% of spoken language.
A new understanding of the evolutionary significance of this myelinated vagal branch (e.g., straited facial, middle ear, ocular) represented a huge paradigm shift towards a much more expansive and nuanced understanding of how social-emotional engagement came to serve a new and hierarchical transformational role in regulating autonomic functioning, beginning with the evolution of the shut down or immobilzation response in the reptilian brain to the fight/flight response in the mammalian brain and how each of these features are hierarchically structured (primitive, limbic, neocortex) in our own phylogeny and either optimally regulated (e.g., calm, well-regulated deepening back and-forth social-emotional engagement, including complex ideation and expressive language - that is core human executive functioning) or circumvented and recruited to primitive or regressive functioning (e.g., fight, flight or an immobilization response) by these three contiguous but evolutionary distinct vagal pathways (see, Porges, S. 1995. The Polyvagal Theory).*
Neurotypical Development, the maturation of the brain: Birth to Three.
The neuroscientific evidence over the last several decades clearly demonstrates a direct correlation between forming healthy neuronal [brain] patterns of connectivity and child/primary caregiver nurturance based practices: The nature of child/caregiver deepening affect reciprocal attachment and complex two-way reciprocal emotional problem solving (e.g., back and forth co-referencing with visual-facial, auditory prosodic and tactile gestural exchanges) with respect to building the emotional foundations of the child's healthy core "sense of self" and correspondingly the child's intact, integrated and healthy emerging developmental milestones (i.e., social-emotional relating, thinking and nonverbal to verbal communicating) have been well established in the fields of infant mental health, epigenetic research on deepening reciprocal attachment and affect regulation on right to left brain development beginning in utero and early childhood, clinical and developmental, psychotherapy and psychoanalysis.
For example, since the 1990's this has been corroborated by extensive neuroscientific research that clearly demonstrates that the healthy integration of each infant's sensory and motor connections and how these inchoate connections, incipient neuronal pathways from birth, turn on genes, produce proteins and form into complex synaptic patterns (the maturation of the wiring of the neuronal pathways) including the maintenance of healthy vagal tone (e.g., autonomic regulation and heart rate variability) are directly dependent upon highly emotionally attuned and responsive primary caregiver interactions. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318551/
For the seminal ground breaking work that began to transform the former disparate fields of neuroanatomy, neurobiology, early infant child mental health, psychoanalysis, family law and Developmental psychology into a new understanding and synthesis, an over-arching theoretical framework and a new foundation for Affect Developmental evidenced based treatment practice see, Schore, Allan, 1994, Affect Regulation and the Origin of Self: The Neurobiology of Emotional Development.
Absolutely brilliant presentations by Allan Schore, 2017, The First 1000 Days of Life: A Critical Period For Shaping Our Emotional Selves and Brains: https://www.youtube.com/watch?v=lY7XOu0yi-E&t=6s
Allan Schore, 2017, The Development Of The Right Brain Across the Lifespan. What’s Love Got to do With It? https://www.youtube.com/watch?v=u_B6WekX75s&t=5030s
The understanding of this fundamental and highly nuanced child/primary caregiver dyadic, triadic and multi-social framework (indeed, if we look at the extended family system) can be correctly conceived of in terms of a significant paradigm shift or the bridging of the fields of Developmental psychology and neurobiology with respect to a new and comprehensive understanding of the formerly viewed disparate biological, psychological-and-social components. This critically encompasses the relational (epigenetic factors) of early infant/toddler/primary caregiver secure or insecure attachment practices that significantly determines the trajectory of what and how genes turn on and off, produce proteins and form and maintain healthy or unhealthy neuronal connectivity (what internationally renown attachment researcher and psychiatrist, Dr. Dan Siegal has termed, “Interpersonal Neurobiology”).
Justifiably, this is now conceptualized as the underlying foundation of developmental social pragmatic evidenced based treatment practices such as DIR/Floortime in understanding and guiding primary caregivers in early infant and childhood mental health as well as treating children with autism spectrum challenges. The latter is a fundamental move away from the past traditional cognitive dissonance of brain treated apart from body or applied behavioral analysis of targeting, “surface behaviors” toward a social-emotional mind-brain-body integrated approach in accordance to twenty-five years of research in Developmental Affect Neuroscience. Due to the advances in technology over the last twenty-five years we can now more accurately measure our data (adult-child inter-brain connections) in real-time (i.e., PET, fMRI ) and thus concretely evince a direct correlation and impact between neuronal growth (e.g., synaptic formation and interconnectivity across different parts of the brain) in healthy child/caregiver nurturance or conversely impaired neuronal activity due to unhealthy nurturance practices. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3968319/ http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0181066
I have provided at the end of this section several additional links to some audio and video discussions for families and clinicians working in the field on what actually constitutes the healthy affective basis of childhood development (i,e., the roots of emotional intelligence). Now, given a child's healthy underlying biological and immune system, the perennial question prior to 1990's was, "What is it that brings the early developing parts of the infant's brain (primitive reflexes, senses and emotions: heart rate variability, breathing, blinking, sensations to sense of touch warmth; auditory, soothing or alarming voice, vision, etc.) into organized and meaningful affective patterns of simple reciprocal co-regulated engagement (optimal arousal for attending, relating and engaging)?" The answer given by Developmental affect neuroscience is the co-regulated partner(s) or "adult higher brain(s)" (the primary caregivers) with the prenatal and postnatal newly forming brain of the child. This is the foundational social-emotional symbiotic relationship absolutely critical for all infant/toddler social-emotional-cognitive development.
Again, what is required to bring the emerging "social brain" of the infant/toddler online with respect to basic executive functioning from simple to increasingly complex engagement with others (e.g., regulated/co-regulated sensory-affect-motor ideation, sequencing and engagement) is the more experienced or higher brain of the primary caregiver or more specifically the child/primary caregiver dyad, Every human infant is born with approx. 84 billion neurons. The human infant is born biologically equipped with a set of basic reflexes. senses and primitive emotional responses. However, the vast majority of neurons that will form into synapses hooking up these complex neuronal pathways (sensory-affect-motor) are highly malleable and thus only loosely connected at birth and only begin to increasingly coalesce into complex neural networks beginning in the last trimester through the first few years of life.
The brain is experience-user/interdependent. The strength of the connectivity and resiliency of the brain's foundations (primitive, limbic and neocortex) are directly co-determined or co-regulated by the "higher brain" of the parent or the child/primary caregiver dyad. This necessitates for optimal integration and resiliency secure attachment, attunement and reciprocal back and forth emotional social engagement (e.g., beginning from birth with the simplest wooing/pleasurable back and forth emotional signaling between parent and child, connecting, breaking and re-connecting child/parent affect facial expressions, games as simple as "peek-a-boo", etc), all of which help co-structure for the child internally well-regulated biopsychosocial patterns with respect to his/her sympathetic and parasympathetic regulation and increased executive functioning. Again, this must begin with healthy child/parent dyad of secure based attachment and deepening expanded attunement through up-regulating joyful play and down-regulating stressful states through soothing. The latter creates the interpersonal neurobiological foundations for increased optimally regulated and resilient complex emotional signaling (e.g., co-emotional gestures, primitive co-prosodic vocalizations, sensory integration, simple to complex ideation to social-pragmatic utterances and phrase receptive and expressive production/exchange)..
The following absolutely brilliant presentation addresses the emotional basis of attachment, affect regulation and cognition, which biopsychosocially exponentially forms during the last trimester into the end of the second to third year of life and which constitutes the unfolding nature and degree of empathy and resiliency of the primary Functional-Emotional Developmental milestones beginning in infancy throughout the lifespan.
Dr. Allan Schore, Modern Attachment Theory: The Enduring Impact of Early Right Brain Development on Affect Regulation, 2012 . https://www.youtube.com/watch?v=c0sKY86Qmzo
Dr. Allan Schore, The Neurobiology And Neuroendorcinology Of Boys At Risk, 2017. https://www.youtube.com/watch?v=P451kiWSBic&t=12s
Dr. Allan Schore: The Neurobiology of Attachment , 2013 (brief clip on explanation of Nurture and Nature; Parent/Child interactive regulation which is crucial in turning on genes to produce proteins which help construct and maintain healthy synaptic growth and development.)
Autism Spectrum And Other Biological-Psychological-Social Developmental Challenges.
What has been far too long ignored in practice by special educators and other clinicians working with children with autism spectrum and other related challenges and too often if at all conveyed to parents (e.g., at the start of early intervention) is the neuroscientific evidence that it is precisely these same principles of healthy nurturance based practices - necessary and indeed critical for each child's core functional emotional developmental milestones (i.e., calm, attentiveness, co-regulated patterns of back and forth emotional regulation, playfulness, ideation) when applied in a therapeutic context (i.e., adjusted or tailored to each child's biological based functional emotional developmental and processing challenges) that does in fact significantly help re-construct new healthy integrated neuronal pathways in the brain.
Guided pleasurable and affectively engaging relationships not just with infants and toddlers but with older children with mild to more involved autism spectrum challenges (due to the brain's enormous neuroplasticity) can not only help facilitate but again as the neuroscientific evidence clearly demonstrates actually re-wire the brain, that is build, strengthen and expand those healthy neural pathways (e.g., improved connectivity between the prefrontal cortex and subcortical functioning and overall integrated sensory-affect-motor functioning - where simple to complex social-emotional affective engagement and pragmatic language development, beginning from the emotional right subcortical regions to linguistic left prefrontal cortex regions can begin to re-wire and strengthen). An expanding database of evidence over the last decade on neuroplasticity is increasingly demonstrating the ability for individuals to re-construct new neuronal connections throughout the lifespan.
The following is an extremely enlightening discussion with regards to much of what I have discussed above with Dr. Stuart Shanker, Distinguished Research Professor of Philosophy and Psychology at York University, entitled Babies, Brain, Nature and Nurture.
Susan Hopkins EdD and Elizabeth Shepherd MSc, "Masking Stress with Misbehavior." This contains important definitions and research underpinning the neurophysiological and developmental understanding of Self-Regulation, where challenges with a child's ability to regulate bio-psycho-social interactions are commonly mistakenly defined as, "Misbehavior." https://selfregulationinstitute.org/reframed-volume-1-issue-1-july-2017-masking-stress-misbehaviour/
American Academy of Pediatrics, August 2018 Clinical Report on Play http://pediatrics.aappublications.org/content/early/2018/08/16/peds.2018-2058
The following is a brief but essential overview of the six core strengths necessary for healthy child development by Dr. Bruce Perry, American psychiatrist, currently the Senior Fellow of the Child Trauma Academy in Houston, Texas and an Adjunct Professor of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine in Chicago, Illinois,
The Root of Empathy Symposium: 2017 . Dr. Bruce Perry, Born For Love:: Why Empathy Is Essential And Endangered
The following is an extraordinarily important video clip with regards to a well-known experiment by internationally acclaimed, Developmental psychologist, Edward Tronick, Director of Child Development Unity and Distinguished Professor at University Massachusetts,, Boston. He is a research associate in Newborn Medicine, a lecturer at Harvard Medical School. He is well known for his research on infant/child caregiver dyadic attachment and what transpires when that emotional connection is disrupted or withdrawn: The Still Face Paradigm:
The following video clip, "Attunement and Why It Matters", by David E. Arrendondo, M.D., briefly illustrates what happens between infant/primary caregiver with respect to neuronal connectivity and attunement during deepening reciprocal attachment and emerging co-emotional signaling.
Below is one of the most important seminal papers written in 2004 by the late Stanley Greenspan, M.D. with respect to the role of affect (or the emotions) constituting typical and non-typical developmental pathways. It is absolutely critical reading:
"Developmental Pathways To and From Autism: The Role of Emotions in the Core Deficit in Autistic Spectrum Disorders-- The Affect Diathesis Hypothesis."
Below are two very brief video clip introductions on the "Mirror Neuron System", by Dr. Dan Siegal, Distinguished Fellow of the American Psychiatric Association and is the Executive Director of the Mindsight Institute. Founding Co-Director of the UCLA Mindful Awareness Research Center. He serves as the Medical Director of the Lifespan Learning Institute. The mirror neuron system is largely regarded as challenged with many individuals diagnosed with ASD. It is part of the brain directly responsible for the ability of individuals to empathically identify, register, interpret, understand and predict the "intentionality" of another's action or what has been traditionally referred to as "Theory of Mind."
Dr. Dan Siegal presents below an in-depth discussion on interpersonal neurobiology, "The Neurological Basis of Behavior, the Mind, the Brain and Human Relationships."
***Dr. Dan Siegal, Roots of Empathy: Research Symposium, 2016. An Interpersonal Neurobiology Approach to Resilience and the Development of Empathy.
Dr. Allan Schore: 2014 The Most Important Years of Our Life: Our Beginnings https://www.youtube.com/watch?v=KW-S4cyEFCc&t=752s
Dr. Allan Schore. Roors of Empathy: Research Symposium, 2016.: Modern Attachment: The impact of Right Brain Development on Affect Regulation
*The Polyvagal theory first introduced by Stephen Porges, M.D., in 1995 provided a new and transformative neurophsyiological understanding of the necessary and indeed critical mammalian/human evolutionary factors of social-emotional engagement (executive functioning) that regulates autonomic functions that are a functional part of the myelinated pathway of the vagus system connected from the heart to the basal ganglia, striated facial muscles, auditory system and vocal system.
The Polyvagal Theory, 2009: New insights into the adaptive reactions of the autonomic nervous system, Stephen W, Porges, M.D.
The Polvagal Perspective, 2007, Stephen Porges, M.D.
Steven Porges, M.D., Human Nature and Early Experience (an in-depth discussion on the neurophysiological correlates that constitute the foundation for a biopsychosocial understanding on how typical and non-typical infants begin to learn, grow and thrive.)
Stephen Porges, MD.,, The Neuroscience and the Power of Safe Relationships (self regulation/co-regulation)
Stephen Porges, M.D., Polyvagal Theory: Co-Regulation in Therapy
Dr. Stephen Porges Website: Infant Developmental Update Study
Stephen Porges, M.D.,, "The Polyvagal Theory."
Stephen Porges, M.D.,, 2011, Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation.
Dr. Stephen Porges: Discussion on "Misophonia."
Colwyn Trevarthen, 2014 Pathways to Child Flourishing: The Love of Special Companions and the Importance Of Play. What is it Being Human and How Can It Survive.
Daniel Stern, 2010, A Developmental Perspective From Birth On. (a discussion on the synthesis of psychoanalysis and the developmental model)
Dr. Stuart Shanker: Self-Regulation: Roots of Empathy Symposium 2014
**The following is an extremely important link for all primary caregivers and clinicians with respect to advocacy for their children, intervention guidance, ,public policy, insurance coverage and the adjoining supportive research evidence for a comprehensive Developmental Relationship based approach such as DIR/Floortime, as well as included are answers to common questions from families on ABA which is distortedly presented as the only evidenced-based treatment approach for children with ASD and related challenges.