Floortime and Pivotal Response Training

Connie Anderson, Ph.D.
IAN Community Scientific Liaison

ian@kennedykrieger.org

Date Published: July 13, 2012

In an earlier article we described Applied Behavior Analysis (ABA), a centerpiece of many autism-focused intervention programs. In this article, we introduce a competing approach, called Floortime, as well as an intervention that combines important features of both ABA and Floortime: Pivotal Response Training.

The ABA Umbrella

ABA is used to increase positive behaviors, reduce behaviors that are harmful or interfere with learning, and help children acquire language, develop social skills, and make academic gains. There is substantial evidence that ABA is effective for many children with autism spectrum disorders (ASDs), especially if it is provided intensively and early.^1,2,3

Because of its success, variations and elements of ABA have been incorporated into a variety of treatment approaches. It has become something of an umbrella term, a catchall for any intervention that uses the science of learning and behavior to increase positive behaviors or decrease negative ones. Discrete Trial Training (DTT), Verbal Behavior (VB), and Incidental Teaching (IT) are all examples of therapies that fit under the ABA umbrella.

Due to this variability, it is sometimes hard to know what someone means by ABA.⁴  Do they mean a very strict DTT program, performed by a licensed ABA specialist, in the home or in a clinic? Or a regimen that devotes some part of the day to DTT, another part to a less restrictive form of ABA, and the rest to other interventions, perhaps within a special education preschool program? What about programs that train parents to perform some ABA-type therapy at home? When inquiring about ABA therapy, parents should ask for details because the term ABA can mean many things.

Criticism, Alternatives, and Adaptations

There have been some criticisms of ABA, despite its successes. Many of these are focused on DTT. Some have suggested that the repeated drills of DTT are artificial, leading to robotic behavior and a failure to generalize skills so a child can use them outside the therapy setting. ABA practitioners respond that this is not the case if ABA is done properly, and that a rich, varied program using a number of different approaches is required. ^4,5

Still, it is clear that when only DTT is used in an inflexible manner, things can go wrong. A team of clinicians who were often called in to help solve behavior problems found: "The misapplication of DTT procedures may lead to students with autism engaging in low levels of escape-motivated behavior (e.g. turning away from the instructor, pushing materials away, signing 'break,' verbalizing 'no') during the initial trials, followed by more extreme escape-motivated behaviors (e.g. self-injury, aggression) during subsequent trials." ⁴

This illustrates another aspect of "pure" behavioral therapies that has been criticized: They are generally adult-driven, and at risk of focusing on procedures and data collection at the expense of the child as a person.

An Alternative Approach: DIR/Floortime

Dr. Stanley Greenspan developed a different treatment approach. Just like those doing ABA, he wanted to get the development of children with ASD back on track. However, he was more interested in emotional connection than in behavior.⁶  He viewed the social and relational deficits of children with ASD as the core issue, and the thing that blocked children from gaining more complex social relating and abstract thinking. He called his approach the Developmental, Individual-Difference, Relationship-Based (DIR) model. DIR’s most well-known component is Floortime, so it is now often called DIR/Floortime.^7,8,9

Unlike ABA, DIR/Floortime is a completely child-led approach, which may indeed take place on the floor as an adult follows a child’s lead and focuses on whatever toys or objects interest the child. For example, if a child were spinning the wheels on some toy cars, an adult might get on the floor right beside him and spin the wheels on cars, too. The point would be to catch the child's interest and his glance, and to share his pleasure or his frustration. Spending time with the child, and entering his world in this way, provides opportunities for connection, and therefore, for ever more complex emotional and social relating. At the same time, because the focus is on a child’s overall development, every area of lagging development is addressed, including motor, sensory, emotional, cognitive, and language functioning.^7,8,9

In 2009, the National Autism Center evaluated how much evidence supports each major autism treatment. They gave behavioral treatments such as ABA a rating of “established,” which means “sufficient evidence is available to confidently determine that a treatment provides beneficial treatment effects.” In contrast, DIR/Floortime only received a rating of “emerging,” which means there have been a few studies that show the treatment is effective, but more high-quality studies are needed.²

There are a number of reasons for this. ABA, with its focus on observable behaviors and careful collection of data, is at a great advantage when it comes to proving its effectiveness. In contrast, data collection is not built into DIR/Floortime. Staying emotionally attuned to a child while following his lead doesn’t mesh well with taking detailed notes of every interaction, and it is harder to collect evidence of increased relating or abstract thinking than it is to count behaviors in a discrete trial. In any case, there have been fewer studies on DIR/Floortime, and many have lacked a control group so researchers could not compare children who did and did not receive the intervention.

Despite this, preliminary research on Greenspan’s model has been considered promising,^{7,10,11,12,13}, and at least one recent study, though small, did include a control group and demonstrated that DIR/Floortime is effective.¹⁴  Proponents of DIR/Floortime claim that it can deliver significant gains in some children, and at a much lower cost than behavioral approaches. It also can often be delivered by parents, and requires fewer hours of therapy to be effective.¹²

Child-Led and Behavioral: PRT

As often happens when two ways of dealing with something are impressive, people start to draw from both of them. Many approaches, with a variety of labels, now include both behavioral and child-led, relational components. One of the most well known of these is Pivotal Response Training or PRT.

Like Dr. Greenspan, Drs. Robert and Lynn Koegel at the University of California, Santa Barbara believed that some of the deficits in children with ASD are more fundamental than others. Improve a child’s ability in one of these pivotal areas, and functioning in many areas would improve.¹⁵  They viewed motivation, especially social motivation, as most important of all. If children gained more motivation to initiate and respond to the social world, they believed, it would “reverse the cycle of impairment” in these children. Self-management — that is, a child’s ability to regulate his own mood and behavior — and self-initiation, a child’s willingness to reach out and create social and learning interactions, are also considered pivotal targets for intervention.¹⁶

The Koegels employed the same behavioral principles of ABA, but left behind the “child and teacher at the table” model. Instead, they took what they call a “more naturalistic” approach, placing a child in a structured space full of opportunities to play and interact. As in Floortime, the adult follows the child’s lead, permitting the child to choose topics of conversation, toys, or activities, and turning them into learning opportunities. As in ABA, the child is rewarded for desirable behaviors, but the behavior is not demanded. Instead, it is caught as it happens.¹⁶

In 2011 the Autism Science Foundation funded research on the use of PRT with babies for the earliest intervention possible. Listen to researcher Jessica Bradshaw explain her work.

Dr. Robert Koegel contrasts this with DTT: “Children often detest ‘drill practices’ used in other forms of autism therapy leading to therapy resistance, frustration, and tantrum throwing. This causes parents a great deal of stress. PRT is different. Parents love it because their children do and this leads to a decrease in their stress level. PRT is effective in all of the children’s environments and versatile enough to use at home, in clinical settings, in an inclusive classroom, and in the community, and parents can easily start folding PRT strategies into the child’s established routine right away.” ¹⁵

PRT has been shown to be effective based on data carefully collected on many aspects of the intervention.^17,18,19   Like ABA, it has been given a rating of “established” by the National Autism Center.²

ABA, DIR/Floortime, and PRT have all been used successfully, and sometimes in combination, to treat children with ASD. Although their principles may be applied to older individuals, they were developed for very young children. What treatments are available for older individuals with ASD? In the third part of this series, we will discuss one of them: Cognitive Behavioral Therapy or CBT.

Additional Resources: 

• The Interdisciplinary Council on Developmental and Learning Disorders’ website – for information on DIR/Floortime
• A Tale of Two Schools – a Time magazine article comparing schools founded on principles of ABA vs. Floortime.
• U.C. Santa Barbara Koegel Autism Center website – for information on PRT.

References

1. Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Development and psychopathology, 20(3), 775-803. View Abstract
2. National Autism Center. (2009). National standards report: Addressing the need for evidence-based practice guidelines for autism spectrum disorders. Randolph, Massachusetts: Author. View Report
3. National Research Council, Committee on Educational Interventions for Children with Autism. (2001). Educating children with autism.National Academy Press. View Online Book
4. Steege, M. W., Mace, F. C., Perry, L., & Longenecker, H. (2007). Applied behavior analysis: Beyond discrete trial teaching. Psychology in the Schools, 44(1), 91-91-99.
5. Rudy, L. J. (2009). Can applied behavior analysis make children robotic? Retrieved 06/29, 2012, from http://autism.about.com/od/alllaboutaba/f/ABArobotic.htm   View Article
6. Greenspan, S. I., Brazelton, T. B., Cordero, J., Solomon, R., Bauman, M. L., Robinson, R., et al. (2008). Guidelines for early identification, screening, and clinical management of children with autism spectrum disorders. Pediatrics, 121(4), 828-830. View Article
7. Greenspan, S. I., & 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 disorders. Journal of Developmental and Learning Disorders, 1(1).
8. Greenspan, S. I. (2007). The developmental individual-difference, relationship-based (DIR/Floortime) model approach to autism spectrum disorders. In E. Hollander, & E. Anagnostou (Eds.), Clinical manual for the treatment of autism (pp. 179-179-209). Arlington, Virginia: American Psychiatric Publishing, Inc.
9. Wieder, S., & Greenspan, S. I. (2003). Climbing the symbolic ladder in the DIR model through floor time/interactive play. Autism : the international journal of research and practice, 7(4), 425-435. View Abstract
10. Committee on Children With Disabilities. (2001). Technical report: The pediatrician's role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics, 107(5), E85. View Abstract
11. 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 : JDBP, 26(2), 77-85. View Abstract
12. Solomon, R., Necheles, J., Ferch, C., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The PLAY project home consultation program. Autism : the international journal of research and practice, 11(3), 205-224. View Abstract
13. Gutstein, S. E., Burgess, A. F., & Montfort, K. (2007). Evaluation of the relationship development intervention program. Autism : the international journal of research and practice, 11(5), 397-411. View Abstract
14. Pajareya, K., & Nopmaneejumruslers, K. (2011). A pilot randomized controlled trial of DIR/Floortime parent training intervention for pre-school children with autistic spectrum disorders. Autism : the international journal of research and practice, 15(5), 563-577. View Abstract
15. Brookes Publishing. (2008). An interview with Robert Koegel. Retrieved 07/03, 2012, from http://www.brookespublishing.com/autism/prt/interview.htm
16. Koegel, R. L., Koegel, L. K., & McNerney, E. K. (2001). Pivotal areas in intervention for autism. Journal of clinical child psychology, 30(1), 19-32. View Abstract
17. Baker-Ericzen, M. J., Stahmer, A. C., & Burns, A. (2007). Child demographics associated with outcomes in a community-based pivotal response training program. Journal of Positive Behavior Interventions, 9(1), 52-52-60.
18. Koegel, R. I., & Frea, W. D. (1993). Treatment of social behavior in autism through the modification of pivotal social skills. Journal of applied behavior analysis, 26(3), 369-377. View Abstract
19. Vismara, L. A., & Lyons, G. L. (2007). Using perseverative interests to elicit joint attention behaviors in young children with autism: Theoretical and clinical implications for understanding motivation. Journal of Positive Behavior Interventions, 9(4), 214-214-228.