Physical & Occupational Therapy in Pediatrics, 34(4):356–367, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/potp DOI: 10.3109/01942638.2014.918074
ORIGINAL RESEARCH
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Home-based DIR/FloortimeTM Intervention Program for Preschool Children with Autism Spectrum Disorders: Preliminary Findings Shu-Ting Liao1 , Yea-Shwu Hwang1 , Yung-Jung Chen2 , Peichin Lee3 , Shin-Jaw Chen4 , & Ling-Yi Lin1 1
Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan, 2 Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, 3 School of Occupational Therapy, Chung Shan Medical University, Taichung, Taiwan, 4 Yin’s Clinic, Tainan, Taiwan
ABSTRACT. Improving parent–child interaction and play are important outcomes for children with autism spectrum disorder (ASD). Play is the primary occupation of children. In this pilot study conducted in Taiwan, we investigated the effects of the developmental, individual difference, and relationship-based (DIR)/FloortimeTM home-based intervention program on social interaction and adaptive functioning of children with ASD. The participants were 11 children with ASD, ages from 45–69 months, and their mothers. Mothers were instructed the principles of the approach by an occupational therapist. All 11 children and their mothers completed the 10-week home-based intervention program, undergoing an average of 109.7 hr of intervention. Children made significant changes in mean scores for emotional functioning, communication, and daily living skills. Moreover, the mothers perceived positive changes in their parent-child interactions. The findings of this pilot study contribute to knowledge regarding the effects of home-based DIR/FloortimeTM intervention program on increasing the social interaction and adaptive behaviors of children with ASD in Taiwan. KEYWORDS: Adaptive functioning, autism spectrum disorders (ASDs), DIR/FloortimeTM , emotional functioning, home program, home-based
Autism spectrum disorder (ASD) is a lifelong developmental disability that is characterized by impairments in communication and reciprocal social interaction, and as well as restricted and repetitive behaviors or interests (American Psychiatric Association [APA], 2000). The Centers for Disease Control and Prevention in the United States (2012) have estimated that an average of one in 88 children has ASD. In addition, reports indicate that the prevalence of ASD is increasing in Western Address correspondence to: Ling-Yi Lin, Sc.D., Assistant Professor, Department of Occupational Therapy, College of Medicine, National Cheng Kung University, No. 1 University Road, Tainan City 701, Taiwan (E-mail: [email protected]). (Received 25 August 2013; accepted 11 April 2014)
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countries as well as in Taiwan (Lin et al., 2009). In 2007, the annual rate of increase in ASD prevalence was 16.5%, the highest among all disabilities (Taiwan Ministry of the Interior [TMOI], 2008). The number of identified persons with ASD in Taiwan was 12,339 in 2012 (TMOI, 2013). Thus, effective interventions are needed to improve the function of children with ASD. The National Research Council (2001) recommended that interventions for children with ASD have the following characteristics: (a) An implementation intensity of 25 hr per week (intensive duration); (b) a therapist-to-client ratio of 1:1 or 1:2; (c) early intervention (from 18 months to 6 years of age); and (d) structured and strategic approaches for improving language, social, and behavioral deficits. Children with ASD and their families, however, may encounter financial and human resource challenges. When educational and medical resources are limited, interventions with the aforementioned characteristics cannot be feasibly established. Several researchers (Case-Smith & Arbesman, 2008; McConachie & Diggle 2007; Schultz et al., 2011) have asserted that caregivers and family members should be involved in therapy programs that incorporate recommendations into daily routines in order to meet the required intensive duration. The social impairment of children with ASD is a crucial concern. In the past two decades, parent–child interaction has attracted increased attention. Numerous studies (Kim & Mahoney, 2005; Mahoney & Perales, 2003, 2005) have confirmed the importance of parent-child interaction, as well as the value of intervention programs that support parent–child relationships. Parent–child interaction is strongly linked to children’s social abilities (Crouter & McHale, 2005). A qualitative study showed that high-quality parent–child relationships can enable caregivers to build a connection with children (Charles & Berman, 2009). Smith et al. (2008) reported that the use of specific caregiving strategies can moderate the depressive symptom of caregivers. Furthermore, occupational therapists assert that, because play is the primary occupation of children, it provides a natural means for children with ASD to develop social skills (Morrison & Metzger, 2001). The social-pragmatic developmental approach has been recommended for children with ASD (Prizant & Wetherby, 1998). This approach is based on the developmental, individual-difference, relationship-based (DIR)/FloortimeTM model (Greenspan & Wieder, 1997), which was designed to improve children’s language, cognition, emotional, and social skills through meaningful interactive relationships. Family involvement is a crucial aspect of the DIR/FloortimeTM model. In addition, this model emphasizes the notion that real learning occurs not in artificial contexts, but in real contexts, and generalizes acquired skills into various types of social interaction. The DIR/FloortimeTM model comprises six developmental milestones of emotional functioning that allow professionals to assess children’s intellectual and emotional maturity. The critical element of these six developmental milestones is reciprocal communication between the child and the caregiver (Greenspan et al., 2001). The DIR/FloortimeTM model is gaining popularity in Taiwan since parents make great efforts to find a cure for their child’s ASD (Shyu et al., 2010). This approach is of particular interest to occupational therapists as it takes place in the child’s environment, focusing on the child’s occupations, such as play or activities of daily living
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(Case-Smith & Arbesman, 2008). The DIR/FloortimeTM model involved intervention entirely with caregivers of children with ASD. It is designed to assist children with ASD in developing social, emotional, and intellectual capacities and establishing relationships with people. DIR/FloortimeTM refers to the action of caregivers or parents “get down on the floor” and playing with their child for a period of time. Caregivers or parents are instructed to follow the child’s lead during play sessions and attempt to extend what the child does to elicit reciprocal interactions as many as possible. Greenspan and Weider (1997) recommend conducting six to ten 20–30min FloortimeTM sessions per day during play time or activities of daily living. Other studies have reported that children with ASD and their families may benefit from the DIR/FloortimeTM approach (Dionne & Martini, 2011; Greenspan & Wieder, 1997, 2005; Mahoney & Perales, 2003; Pajareya & Nopmaneejumruslers, 2011; Solomon et al., 2007; Wieder & Greenspan, 2003). Children with ASD have been reported to make significant gains in emotional development and to decrease stereotyped behaviors. However, the majority of the studies used convenience sampling rather than randomized sampling and did not include a control group (Dionne & Martini, 2011; Greenspan & Wieder, 1997, 2005; Mahoney & Perales, 2003; Solomon et al., 2007; Wieder & Greenspan, 2003). Only one study was a randomized controlled trial that used reliable and valid outcome measures (Pajareya & Nopmaneejumruslers, 2011). Pajareya and Nopmaneejumruslers (2011) replicated the study of Solomon et al. (2007) and used the Functional Emotional Assessment Scale as the outcome measure for the treatment effect on children with ASD in Thailand. The results showed a positive effect of the DIR/FloortimeTM intervention in promoting emotional functioning suggesting that intervention could be effectively replicated in different cultural settings. A limitation of the study was that the treatment group received a varying amount of intervention. In addition to supporting the development of children with ASD, interventions that involve training parents to interact with their children yield positive effects (Blackledge & Hayes, 2006; Casenhiser et al., 2013; Moes, 1995; Sofronoff & Farbotko, 2002). Children with ASD were involved in interactions with their parents and the quality of the parent–child relationship improved. For example, Moes (1995) reported that parents of children with ASD used strategies to manage children’s difficult behaviors and experienced relatively less stress after participating in a parent-training program. Only one case report has been published regarding the effectiveness of the DIR/FloortimeTM intervention model in Taiwan (Yen et al., 2008). Two psychologists implemented this approach in a clinical setting for two preschool children (46 and 54 months old) with high-functioning autism. These children received 12 and 10 1-hr weekly treatment sessions, respectively. Intervention outcomes were primarily assessed by the researchers’ qualitative observations and did not directly involve caregivers and families. The purpose of this pilot study was to investigate the effects of home-based DIR/FloortimeTM intervention program on increasing the social interaction and adaptive behaviors of children with ASD. Accordingly, this single group and preand posttest design addressed the following questions: (a) Does the home-based
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DIR/FloortimeTM intervention program increase the social interaction and adaptive behaviors of preschool children with ASD? and (b) Do mothers perceive a reduction in their stress levels after undergoing parent–child intervention training? METHOD
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Participants Eleven boys (mean age: 55.9 months; age range: 45–69 months) and their mothers (mean age: 35.7 years; age range: 29–44 years) were recruited as participants. The National Cheng Kung University Hospital internal review board approved the study. Participants were recruited from the hospital clinic, private clinic, and the early intervention centers through the distribution of research fliers. Written informed consent was obtained from the parents before enrolling their child in this study. None of the mothers had previously participated in training that incorporated the DIR/FloortimeTM model. The children’s nonverbal intelligence quotient (IQ), evaluated using the Leiter International Performance Scale-Revised (Roid & Miller, 1997), varied from 67 to 122 (mean: 101.6; SD: 17.8). All of the children had been diagnosed with an autistic disorder by a mental health professional according to the Diagnostic and Statistical Manual IV Text Revision (DSM-IV-TR) criteria (APA, 2000). The severity of disability was based on a combination of the children’s verbal IQ scores (Wechsler Intelligence Scale for Children) and levels of functional language and social adaptation (based on clinical observation or behavioral and adaptation scales). Additional characteristics of the sample are presented in Table 1. Measures Demographic information. The demographic characteristics of the children included age, gender, diagnosis, severity of disability (mild to profound). The demographic characteristics of the mothers included age, gender, education level (no schooling/elementary school to graduate school), marital status (single, married, or otherwise), and employment status (full-time, part-time, or unemployed). These data were obtained at the beginning of the first session. Functional Emotional Assessment Scale. The Functional Emotional Assessment Scale (FEAS; Greenspan et al., 2001) was used to measure changes in the children’s emotional functioning within the context of the relationship with their caregiver. The FEAS is a valid and reliable rating scale that can be used when observing videotaped interactions between children with ASD and their caregivers (Greenspan et al., 2001). The FEAS is based on six functional developmental levels: (a) selfregulation and interest in the world; (b) formulation of relationships, attachments, and engagements; (c) two-way, purposeful communication; (d) behavioral organization, problem solving, and internalization; (e) representational capacity; and (f) representational differentiation. Each capacity can be rated on the 0 to 2 rating scales. Ratings for items are summed to obtain subtest scores as well as a total test score. Higher FEAS scores indicate superior functional behavior and a higher developmental level.
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TABLE 1. Characteristics of Children with Autistic Spectrum Disorders and their Mothers (N = 11)
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Variables Child with ASD Mean age (months) 36–48 months 49–60 months 61–72 months Gender: Male Severity of disability Mild Moderate Mean nonverbal IQ Mothers Caregivers Mean age (years) Level of education Senior high school Bachelor’s degree Master’s degree Marital Status: Married Employment Status Unemployed Part-time/Full-time
M (SD) or n (%)
55.9 (8.9) 4 (36.4%) 3 (27.3%) 4 (36.4%) 11 (100%) 3 (27.3%) 8 (72.7%) 101.6 (17.8) 35.7 (4.2) 2 (18.2%) 8 (72.7%) 1 (9.1%) 11 (100%) 6 (54.5%) 2 (18.2%)/3 (27.3%)
Two 15-min child–caregiver interactions were videotaped for each child immediately before and after intervention. Two trained occupational therapists were asked to independently rate each child’s emotional functioning from the videotapes. The therapists had experience in assessing children with ASD and were unaware of whether they were viewing the pre- or posttest. Interrater reliability between the two occupational therapists was examined for all 11 children. The intraclass correlation coefficient was 0.85 (95% confidence interval: 0.53–0.96) for pretest ratings and 0.94 (95% confidence interval: 0.81–0.99). Vineland Adaptive Behavior Scales. The VABS-II (Sparrow et al., 2005) was used to identify changes in the children’s adaptive behaviors. This scale covers the domains of communication, daily living skills, socialization, and motor skills. Higher scores indicate greater skills. Reliability was established above the 0.80 level for all domains (Sparrow et al., 2005). A Chinese version of the VABS-II has been published and validated for use in a Taiwanese population (Wu et al., 2004). Cronbach’s alpha coefficients for the sample at the pre- and posttest exceeded 0.85 for all domains. Parenting Stress Index-Short form. The Parenting Stress Index-Short Form (PSI/SF; Abidin, 1990) was used to assess mothers’ perceptions of stress. This index comprises 36 items and yields a total stress score from three subscales: parental distress, parent–child dysfunctional interaction, and difficult child. Each item was graded on a five-point Likert scale. Higher scores indicate greater perceived stress among mothers. The Chinese version of the PSI/SF exhibited satisfactory reliability and construct validity (Weng, 1995). The Cronbach’s alpha coefficients of the sample at the pre- and posttest exceeded 0.70 for all subscales.
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Intervention Program The intervention program was based on the principles of the DIR/FloortimeTM intervention developed by Greenspan and Wieder (1997). The first author, an occupational therapist, provided instruction to all families on implementation of the DIR/FloortimeTM intervention. Prior to the study, the first author studied the DIR/FloortimeTM model from books (Greenspan & Wieder, 1997; Interdisciplinary Council on Developmental and Learning Disorders [ICDL], 2009) and a DVD lecture of the PLAY (Play and Language for Autistic Youngsters) Project model. In addition, she underwent 25 hr of structured, intensive, and supervised training in the DIR/FloortimeTM model provided by an experienced therapist who certificated from the ICDL. The Figure 1 presents the process. Before the first session, each mother individually attended a 3-week one-on-one training course at research laboratory with the first author, to learn about the DIR/FloortimeTM model. Mothers also attended a 3hr DVD lecture presented by the first author. The lecture consisted of the basic concepts of the DIR method and play strategies. During each one-on-one session, the mother was trained in the home-based DIR/FloortimeTM intervention program for 2 to 3 hr and set individualized goals for her child. To achieve the identified goals, the mothers were trained to observe their child’s cues, follow the child’s lead, and implement the play strategies that were appropriate for their child’s current level of functional development.
FIGURE 1. The process of the DIR/FloortimeTM intervention program.
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At the beginning of the intervention program, each family received a manual to facilitate the application of play strategies to daily activities. The mothers were asked about their goals and discussed them with the first author. Specific goals and a home program were established according to the results of evaluation and children’s age and development for each family. The mothers were instructed to conduct the home-based DIR/FloortimeTM intervention program for at least 10 hr per week. In addition, the first author met with the mothers and children every 2 weeks to discuss concerns regarding the intervention program or difficulties experienced by the parents or children. All of the mothers completed the 10-week intervention program. The average number of intervention hours for all participants was 109.7 (SD = 38.0, [85–152]). Each child with ASD was instructed to continue his routine programs, including special or preschool education, speech therapy, or occupational therapy. Data Analysis SPSS 17.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze the data. Descriptive statistics were computed for demographic data, independent variables, and outcome measures. Wilcoxon-signed rank tests were performed to examine changes in the children’s emotional functioning and adaptive behaviors, as well as differences in the level of parental stress. The level of significance was set at p < .05. An effect size index r was established on the basis of the z score divided by the square root of the total sample (low effect size: 0.30 > r ≥ 0.10, medium effect size: 0.50 > r ≥ 0.30, large effect size: r ≥ 0.50; Cohen, 1988). RESULTS Functional Emotional Assessment Scale Mean scores for the overall FEAS and the six FEAS domains increased over the 10-week intervention (Table 2). The effect size for the total score was 0.49 and varied from 0.30 to 0.58 for the six domain scores (medium to large effect). Differences were significant for the total score (Z = −2.31, p < .05) and the domains engagement and relating (Z = −2.44, p < .05), two-way purposeful emotional interaction (Z = −2.70, p < .01), and social problem solving (Z = −2.50, p < .05). Vineland Adaptive Behavior Scales The effect size for the VABS-2 varied from 0.43 to 0.52 (medium to large effect) except for motor skills (0.21) (Table 2). There were significant improvements in the total score (Z = −2.19, p < .05) and the domains communication (Z = −2.02, p < .05), daily living skills (Z = 2.45, p < .05), and social (Z = −2.09, p < .05). Parenting Stress Index-Short Form The effect size was small for the change in total score (0.27) and subscale scores for parental distress (0.17) and difficult child (0.27). There was a significant (Z = −2.11, p < .05) decrease in the parent–child dysfunctional interaction score; the effect size was medium (0.45) (Table 3). The latter finding indicates that mothers perceived greater positive parent–child interactions following the intervention.
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TABLE 2. Changes in Functional Emotional Assessment Scale and Vineland Adaptive Behaviors Scales by Children with ASD
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Measure Functional Emotional Assessment Scale Total Score Self-regulation and interest in the world Forming relationships, attachment, and engagement Two-way, purposeful communication Behavioral organization, problem solving, and internalization Representational capacity Representational differentiation Vineland Adaptive Behavior Scale—second edition Total Score Communication Daily Living Skills Socialization Motor Skills
Statistics
Pretest M (SD)
Posttest M (SD)
p
Effect Size
30.6 (13.6) 10.5 (2.6) 7.4 (3.4) 4.2 (2.3) 1.6 (1.2)
39.8 (16.8) 11.9 (3.1) 10.6 (4.7) 5.7 (2.4) 2.5 (1.1)
< .05 0.12 < .05 < .01 < .05
0.49 0.33 0.52 0.58 0.53
5.0 (3.6) 2.1 (2.3)
6.0 (4.1) 3.1 (2.9)
0.28 0.16
0.23 0.30
154.3 (56.9) 43.5 (17.9) 52.4 (25.2) 21.2 (10.9) 37.3 (9.6)
173.5 (65.1) 48.0 (20.5) 60.7 (24.4) 25.8 (15.3) 38.9 (10.2)
< .05 < .05 < .05 < .05 0.33
0.47 0.43 0.52 0.45 0.21
DISCUSSION There are several limitations that are important to consider when interpreting the results. This was a single group design and, therefore, the effect of maturation and other services and supports were not controlled. In addition, the mothers’ were a sample of convenience who expressed interest in their children receiving additional services. They may not reflect the attitudes and beliefs of all mothers of young children with ASD. The results provide preliminary evidence of the effects that the home-based DIR/FloortimeTM intervention program have on increasing the social interaction and adaptive behaviors of children with ASD in Taiwan. This research provides three main findings. First, children made significant improvements in two-way purposeful communication, forming relationships, behavioral organization, and problem solving following the home-based DIR/FloortimeTM intervention program. The effect size varied from medium to large. Second, the adaptive functioning of the children improved, especially communication and daily living skills. The effect size varied from medium to large. Third, the mothers perceived positive changes in their parent–child interactions after implementing the home-based DIR/FloortimeTM intervention program. TABLE 3. Changes in Parenting Stress Index: Short Form by Children with ASD (n = 11)
Measures Total score Parental distress Parent–child dysfunctional interaction Difficult child
Statistics
Pretest M (SD)
Posttest M (SD)
p
Effect Size
106.9 (11.8) 37.3 (7.1) 32.6 (5.3) 37.1 (6.4)
100.0 (15.0) 35.9 (6.1) 30.0 (5.6) 34.1 (7.1)
0.21 0.41 < .05 0.20
0.27 0.17 0.45 0.27
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Consistent with the results of previous studies (e.g., Pajareya & Nopmaneejumruslers, 2011; Solomon et al., 2007), we found that training in the home-based DIR/FloortimeTM intervention program was effective for enhancing the development of children with ASD. In our study, the average total FEAS score increased from 30.6 to 39.8, a medium effect size. Our findings correspond to those of a similar to 3-month study conducted in Thailand (Pajareya & Nopmaneejumruslers, 2011). The intervention period in our study was shorter (10 weeks) and less intense (average of 10 hr per week) compared with Pajareya and Nopmaneejumruslers (average of 15.2 hr for 3 months). The results are encouraging because they suggest that interventions performed by mothers at home can be effective. Our results indicate that the children made significant gains in adaptive skills. Notably, many related studies (e.g., Klin et al., 2007; Szatmari et al., 2003) have focused primarily on the socialization and communication, and have overlooked the daily living skills (Jasmin et al., 2009). Few interventions have been designed to target daily living skills. In our study, children with ASD achieved functional improvements in their daily living skills over the 10-week intervention. Greenspan and Weider recommended that caregivers execute six to ten 20–30-min DIR/FloortimeTM interventions per day during play time and activities of daily living (Greenspan & Wieder, 1997). The home-based DIR/FloortimeTM intervention program developed in this study satisfied this recommendation and equipped mothers with strategies for cultivating children’s functional and developmental skills. In Chinese, the parent–child relationship is embedded in a hierarchical family structure. Interactions between parents and children are connected to the notion of parental control and governance (Wu, 2013). We observed that the mothers perceived improvements in their parent–child interactions after the intervention. The mothers in this study were taught how to play with their children in a natural environment. Many of the mothers reported that they did not know how to play with their child at the beginning of the study. By contrast, after completing the training, they were confident and eager to play with their children. These observations suggest the importance of collaboration with mothers of children with ASD on strategies for play. Nevertheless, no significant improvements in the subscales of Parental Distress or Difficult Child were observed. According to Abidin (1990), parental distress reflects complex aspects, including perceptions of child-rearing competence, conflict with a spouse or partner, social support, and stresses associated with restrictions placed on other life roles. The subscale Difficult Child reflects the caregiver’s view of a child’s temperament, noncompliance, and demands. Changes to these subscales might not be noticeable in a short intervention period. Several studies have suggested that mothers of children with ASD experience high levels of distress, and that the sources of parental stress are confounding factors (Mori et al., 2009; Tomanik et al., 2004). One possible explanation is that the intensive interventions and consultations support provided every 2 weeks in this study primarily focused on improving the interaction between parents and children and the acquisition of play skills. Accordingly, the mothers perceived substantial changes in their parent–child interactions. Further research is recommended to identify strategies for reducing parental distress related to behavioral problems of children with ASD.
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With respect to implications for practice, the results are useful for occupational therapists to assist mothers to carry out the home-based DIR/FloortimeTM intervention program for children with ASD in Taiwan. Therapists could involve mothers in direct treatment in order to coordinate center/hospital and home programs. Further research including randomized controlled trials is needed to substantiate the results of our study with greater number of participants. We could not control for the effects of normal development, and certain confounding factors (such as family environment, maternal personality traits, etc.). Consideration should be given to including covariates such as severity of ASD symptom and mothers’ wellbeing and interactions when analyzing outcomes. CONCLUSION This study provides preliminary evidence of the effectiveness of a 10-week home-based DIR/FloortimeTM intervention program for preschool age children with ASD and their mothers. Children made significant improvement in emotional functioning including two-way communication, behavioral organization, and relationship forming. Furthermore, their adaptive functioning improved, especially in communication and social skills. Further research, including randomized controlled trials, are recommended to determine the effectiveness of DIR/FloortimeTM intervention program in improving social interaction and adaptive behaviors of preschool children with ASD. ACKNOWLEDGMENTS Support for this research was provided by the Taiwan Ministry of Education under the NCKU Aim for the Top University Project for Promoting Academic Excellence & Developing World Class Research Centers. We thank all the families that participated. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. ABOUT THE AUTHORS Shu-Ting Liao, M.S., Yea-Shwu Hwang, Sc.D., and Ling-Yi Lin, Sc.D., Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan. Yung-Jung Chen, M.D., DMSci, Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. Peichin Lee, Ph.D., School of Occupational Therapy, Chung Shan Medical University, Taichung, Taiwan. Shin-Jaw Chen, M.D., Dr. Yin’s Clinic, Tainan, Taiwan REFERENCES Abidin RR. (1990). Parenting stress index/short form. Lutz, FL: Psychological Assessment Resources. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Association.
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Morrison C, Metzger P. (2001). Play. In: Case-Smith J, ed. Occupational therapy for children. St. Louis: Mosby, 528–544. National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Educational Interventions for Children with Autism. (2001). Educating children with autism. Washington, DC: National Academy Press, 11–31. 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 15:1–15. Prizant BM, Wetherby AM. (1998). Understanding the continuum of discrete-trial traditional behavioral to social-pragmatic developmental approaches in communication enhancement for young children with autism/PDD. Seminars in Speech and Language 19:329–351. Roid GH, Miller LJ. (1997). Leiter-R examiners manual. Wood Dale, IL: Stoelting Co. Schultz TR, Schmidt CT, Stichter JP. (2011). A review of parent education programs for parents of children with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities 26:96–104. Shyu Y, Tsai J, Tsai W. (2010). Explaining and selecting treatments for autism: Parental explanatory models in Taiwan. Journal of Autism and Developmental Disorders 40:1323–1331. Smith LE, Seltzer MM, Tager-Flusberg H, Greenberg JS, Carter AS. (2008). A comparative analysis of well-being and coping among mothers of toddlers and mothers of adolescents with ASD. Journal of Autism Development Disorder 38:876–889. Sofronoff K, Farbotko M. (2002). The effectiveness of parent management training to increase self-efficacy in parents of children with Asperger syndrome. Autism 6:271–286. 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 11:205–224. Sparrow SS, Cicchetti DV, Balla DA. (2005). Vineland adaptive behavior scales (2nd ed.). Circle Pines, MN: AGS Publishing. Szatmari P, Bryson SE, Boyle MH, Streiner DL, Duku E. (2003). Predictors of outcome among high functioning children with autism and Asperger syndrome. Journal of Child Psychology and Psychiatry 44:520–528. Taiwan Ministry of the Interior. (2008). Statistical yearbook of interior (in Chinese). Retrieved August 21, 2012, from http://sowf.moi.gov.tw/stat/week/list.htm Taiwan Ministry of the Interior. (2013). Statistical yearbook of interior (in Chinese). Retrieved August 26, 2013, from http://www.moi.gov.tw/stat/news list.aspx Tomanik S, Harris GE, Hawkins J. (2004). The relationship between behaviours exhibited by children with autism and maternal stress. Journal of Intellectual & Developmental Disability 29:16–26. United States Centers for Disease Control and Prevention. (2012). Prevalence of autism spectrum disorders-autism and developmental disabilities monitoring network, 14 sites, United States. Surveillance Summaries, March, 30. Retrieved February 2, 2013, from http://www.cdc.gov/mmwr/pdf/ss/ss6103.pdf Weng YS. (1995). Parenting stress index: Short form—Chinese version. Taipei: Psychological Publishing Company, Ltd. Wieder S, Greenspan SI. (2003). Climbing the symbolic ladder in the DIR model through floor time/interactive play. Autism 7:425–435. Wu MY. (2013). The concept of guan in the Chinese parent–child relationship. In: Yi CC, ed. The psychological well-being of East Asian youth. New York, NY: Springer, 29–49. Wu WT, Cheng CF, Lu HH, Chiu SC. (2004). Vineland adaptive behavior scale—Chinese version. Taipei: Psychological Publishing Company, Ltd. Yen HY, Tseng CC, Soong WT. (2008). A treatment based on the developmental individualdifference, relationship-based model for two preschool children with high-functioning autism: A preliminary report (in Chinese). Formosa Journal of Mental Health 21:221–244.
ORIGINAL RESEARCH
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Home-based DIR/FloortimeTM Intervention Program for Preschool Children with Autism Spectrum Disorders: Preliminary Findings Shu-Ting Liao1 , Yea-Shwu Hwang1 , Yung-Jung Chen2 , Peichin Lee3 , Shin-Jaw Chen4 , & Ling-Yi Lin1 1
Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan, 2 Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, 3 School of Occupational Therapy, Chung Shan Medical University, Taichung, Taiwan, 4 Yin’s Clinic, Tainan, Taiwan
ABSTRACT. Improving parent–child interaction and play are important outcomes for children with autism spectrum disorder (ASD). Play is the primary occupation of children. In this pilot study conducted in Taiwan, we investigated the effects of the developmental, individual difference, and relationship-based (DIR)/FloortimeTM home-based intervention program on social interaction and adaptive functioning of children with ASD. The participants were 11 children with ASD, ages from 45–69 months, and their mothers. Mothers were instructed the principles of the approach by an occupational therapist. All 11 children and their mothers completed the 10-week home-based intervention program, undergoing an average of 109.7 hr of intervention. Children made significant changes in mean scores for emotional functioning, communication, and daily living skills. Moreover, the mothers perceived positive changes in their parent-child interactions. The findings of this pilot study contribute to knowledge regarding the effects of home-based DIR/FloortimeTM intervention program on increasing the social interaction and adaptive behaviors of children with ASD in Taiwan. KEYWORDS: Adaptive functioning, autism spectrum disorders (ASDs), DIR/FloortimeTM , emotional functioning, home program, home-based
Autism spectrum disorder (ASD) is a lifelong developmental disability that is characterized by impairments in communication and reciprocal social interaction, and as well as restricted and repetitive behaviors or interests (American Psychiatric Association [APA], 2000). The Centers for Disease Control and Prevention in the United States (2012) have estimated that an average of one in 88 children has ASD. In addition, reports indicate that the prevalence of ASD is increasing in Western Address correspondence to: Ling-Yi Lin, Sc.D., Assistant Professor, Department of Occupational Therapy, College of Medicine, National Cheng Kung University, No. 1 University Road, Tainan City 701, Taiwan (E-mail: [email protected]). (Received 25 August 2013; accepted 11 April 2014)
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countries as well as in Taiwan (Lin et al., 2009). In 2007, the annual rate of increase in ASD prevalence was 16.5%, the highest among all disabilities (Taiwan Ministry of the Interior [TMOI], 2008). The number of identified persons with ASD in Taiwan was 12,339 in 2012 (TMOI, 2013). Thus, effective interventions are needed to improve the function of children with ASD. The National Research Council (2001) recommended that interventions for children with ASD have the following characteristics: (a) An implementation intensity of 25 hr per week (intensive duration); (b) a therapist-to-client ratio of 1:1 or 1:2; (c) early intervention (from 18 months to 6 years of age); and (d) structured and strategic approaches for improving language, social, and behavioral deficits. Children with ASD and their families, however, may encounter financial and human resource challenges. When educational and medical resources are limited, interventions with the aforementioned characteristics cannot be feasibly established. Several researchers (Case-Smith & Arbesman, 2008; McConachie & Diggle 2007; Schultz et al., 2011) have asserted that caregivers and family members should be involved in therapy programs that incorporate recommendations into daily routines in order to meet the required intensive duration. The social impairment of children with ASD is a crucial concern. In the past two decades, parent–child interaction has attracted increased attention. Numerous studies (Kim & Mahoney, 2005; Mahoney & Perales, 2003, 2005) have confirmed the importance of parent-child interaction, as well as the value of intervention programs that support parent–child relationships. Parent–child interaction is strongly linked to children’s social abilities (Crouter & McHale, 2005). A qualitative study showed that high-quality parent–child relationships can enable caregivers to build a connection with children (Charles & Berman, 2009). Smith et al. (2008) reported that the use of specific caregiving strategies can moderate the depressive symptom of caregivers. Furthermore, occupational therapists assert that, because play is the primary occupation of children, it provides a natural means for children with ASD to develop social skills (Morrison & Metzger, 2001). The social-pragmatic developmental approach has been recommended for children with ASD (Prizant & Wetherby, 1998). This approach is based on the developmental, individual-difference, relationship-based (DIR)/FloortimeTM model (Greenspan & Wieder, 1997), which was designed to improve children’s language, cognition, emotional, and social skills through meaningful interactive relationships. Family involvement is a crucial aspect of the DIR/FloortimeTM model. In addition, this model emphasizes the notion that real learning occurs not in artificial contexts, but in real contexts, and generalizes acquired skills into various types of social interaction. The DIR/FloortimeTM model comprises six developmental milestones of emotional functioning that allow professionals to assess children’s intellectual and emotional maturity. The critical element of these six developmental milestones is reciprocal communication between the child and the caregiver (Greenspan et al., 2001). The DIR/FloortimeTM model is gaining popularity in Taiwan since parents make great efforts to find a cure for their child’s ASD (Shyu et al., 2010). This approach is of particular interest to occupational therapists as it takes place in the child’s environment, focusing on the child’s occupations, such as play or activities of daily living
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(Case-Smith & Arbesman, 2008). The DIR/FloortimeTM model involved intervention entirely with caregivers of children with ASD. It is designed to assist children with ASD in developing social, emotional, and intellectual capacities and establishing relationships with people. DIR/FloortimeTM refers to the action of caregivers or parents “get down on the floor” and playing with their child for a period of time. Caregivers or parents are instructed to follow the child’s lead during play sessions and attempt to extend what the child does to elicit reciprocal interactions as many as possible. Greenspan and Weider (1997) recommend conducting six to ten 20–30min FloortimeTM sessions per day during play time or activities of daily living. Other studies have reported that children with ASD and their families may benefit from the DIR/FloortimeTM approach (Dionne & Martini, 2011; Greenspan & Wieder, 1997, 2005; Mahoney & Perales, 2003; Pajareya & Nopmaneejumruslers, 2011; Solomon et al., 2007; Wieder & Greenspan, 2003). Children with ASD have been reported to make significant gains in emotional development and to decrease stereotyped behaviors. However, the majority of the studies used convenience sampling rather than randomized sampling and did not include a control group (Dionne & Martini, 2011; Greenspan & Wieder, 1997, 2005; Mahoney & Perales, 2003; Solomon et al., 2007; Wieder & Greenspan, 2003). Only one study was a randomized controlled trial that used reliable and valid outcome measures (Pajareya & Nopmaneejumruslers, 2011). Pajareya and Nopmaneejumruslers (2011) replicated the study of Solomon et al. (2007) and used the Functional Emotional Assessment Scale as the outcome measure for the treatment effect on children with ASD in Thailand. The results showed a positive effect of the DIR/FloortimeTM intervention in promoting emotional functioning suggesting that intervention could be effectively replicated in different cultural settings. A limitation of the study was that the treatment group received a varying amount of intervention. In addition to supporting the development of children with ASD, interventions that involve training parents to interact with their children yield positive effects (Blackledge & Hayes, 2006; Casenhiser et al., 2013; Moes, 1995; Sofronoff & Farbotko, 2002). Children with ASD were involved in interactions with their parents and the quality of the parent–child relationship improved. For example, Moes (1995) reported that parents of children with ASD used strategies to manage children’s difficult behaviors and experienced relatively less stress after participating in a parent-training program. Only one case report has been published regarding the effectiveness of the DIR/FloortimeTM intervention model in Taiwan (Yen et al., 2008). Two psychologists implemented this approach in a clinical setting for two preschool children (46 and 54 months old) with high-functioning autism. These children received 12 and 10 1-hr weekly treatment sessions, respectively. Intervention outcomes were primarily assessed by the researchers’ qualitative observations and did not directly involve caregivers and families. The purpose of this pilot study was to investigate the effects of home-based DIR/FloortimeTM intervention program on increasing the social interaction and adaptive behaviors of children with ASD. Accordingly, this single group and preand posttest design addressed the following questions: (a) Does the home-based
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DIR/FloortimeTM intervention program increase the social interaction and adaptive behaviors of preschool children with ASD? and (b) Do mothers perceive a reduction in their stress levels after undergoing parent–child intervention training? METHOD
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Participants Eleven boys (mean age: 55.9 months; age range: 45–69 months) and their mothers (mean age: 35.7 years; age range: 29–44 years) were recruited as participants. The National Cheng Kung University Hospital internal review board approved the study. Participants were recruited from the hospital clinic, private clinic, and the early intervention centers through the distribution of research fliers. Written informed consent was obtained from the parents before enrolling their child in this study. None of the mothers had previously participated in training that incorporated the DIR/FloortimeTM model. The children’s nonverbal intelligence quotient (IQ), evaluated using the Leiter International Performance Scale-Revised (Roid & Miller, 1997), varied from 67 to 122 (mean: 101.6; SD: 17.8). All of the children had been diagnosed with an autistic disorder by a mental health professional according to the Diagnostic and Statistical Manual IV Text Revision (DSM-IV-TR) criteria (APA, 2000). The severity of disability was based on a combination of the children’s verbal IQ scores (Wechsler Intelligence Scale for Children) and levels of functional language and social adaptation (based on clinical observation or behavioral and adaptation scales). Additional characteristics of the sample are presented in Table 1. Measures Demographic information. The demographic characteristics of the children included age, gender, diagnosis, severity of disability (mild to profound). The demographic characteristics of the mothers included age, gender, education level (no schooling/elementary school to graduate school), marital status (single, married, or otherwise), and employment status (full-time, part-time, or unemployed). These data were obtained at the beginning of the first session. Functional Emotional Assessment Scale. The Functional Emotional Assessment Scale (FEAS; Greenspan et al., 2001) was used to measure changes in the children’s emotional functioning within the context of the relationship with their caregiver. The FEAS is a valid and reliable rating scale that can be used when observing videotaped interactions between children with ASD and their caregivers (Greenspan et al., 2001). The FEAS is based on six functional developmental levels: (a) selfregulation and interest in the world; (b) formulation of relationships, attachments, and engagements; (c) two-way, purposeful communication; (d) behavioral organization, problem solving, and internalization; (e) representational capacity; and (f) representational differentiation. Each capacity can be rated on the 0 to 2 rating scales. Ratings for items are summed to obtain subtest scores as well as a total test score. Higher FEAS scores indicate superior functional behavior and a higher developmental level.
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TABLE 1. Characteristics of Children with Autistic Spectrum Disorders and their Mothers (N = 11)
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Variables Child with ASD Mean age (months) 36–48 months 49–60 months 61–72 months Gender: Male Severity of disability Mild Moderate Mean nonverbal IQ Mothers Caregivers Mean age (years) Level of education Senior high school Bachelor’s degree Master’s degree Marital Status: Married Employment Status Unemployed Part-time/Full-time
M (SD) or n (%)
55.9 (8.9) 4 (36.4%) 3 (27.3%) 4 (36.4%) 11 (100%) 3 (27.3%) 8 (72.7%) 101.6 (17.8) 35.7 (4.2) 2 (18.2%) 8 (72.7%) 1 (9.1%) 11 (100%) 6 (54.5%) 2 (18.2%)/3 (27.3%)
Two 15-min child–caregiver interactions were videotaped for each child immediately before and after intervention. Two trained occupational therapists were asked to independently rate each child’s emotional functioning from the videotapes. The therapists had experience in assessing children with ASD and were unaware of whether they were viewing the pre- or posttest. Interrater reliability between the two occupational therapists was examined for all 11 children. The intraclass correlation coefficient was 0.85 (95% confidence interval: 0.53–0.96) for pretest ratings and 0.94 (95% confidence interval: 0.81–0.99). Vineland Adaptive Behavior Scales. The VABS-II (Sparrow et al., 2005) was used to identify changes in the children’s adaptive behaviors. This scale covers the domains of communication, daily living skills, socialization, and motor skills. Higher scores indicate greater skills. Reliability was established above the 0.80 level for all domains (Sparrow et al., 2005). A Chinese version of the VABS-II has been published and validated for use in a Taiwanese population (Wu et al., 2004). Cronbach’s alpha coefficients for the sample at the pre- and posttest exceeded 0.85 for all domains. Parenting Stress Index-Short form. The Parenting Stress Index-Short Form (PSI/SF; Abidin, 1990) was used to assess mothers’ perceptions of stress. This index comprises 36 items and yields a total stress score from three subscales: parental distress, parent–child dysfunctional interaction, and difficult child. Each item was graded on a five-point Likert scale. Higher scores indicate greater perceived stress among mothers. The Chinese version of the PSI/SF exhibited satisfactory reliability and construct validity (Weng, 1995). The Cronbach’s alpha coefficients of the sample at the pre- and posttest exceeded 0.70 for all subscales.
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Intervention Program The intervention program was based on the principles of the DIR/FloortimeTM intervention developed by Greenspan and Wieder (1997). The first author, an occupational therapist, provided instruction to all families on implementation of the DIR/FloortimeTM intervention. Prior to the study, the first author studied the DIR/FloortimeTM model from books (Greenspan & Wieder, 1997; Interdisciplinary Council on Developmental and Learning Disorders [ICDL], 2009) and a DVD lecture of the PLAY (Play and Language for Autistic Youngsters) Project model. In addition, she underwent 25 hr of structured, intensive, and supervised training in the DIR/FloortimeTM model provided by an experienced therapist who certificated from the ICDL. The Figure 1 presents the process. Before the first session, each mother individually attended a 3-week one-on-one training course at research laboratory with the first author, to learn about the DIR/FloortimeTM model. Mothers also attended a 3hr DVD lecture presented by the first author. The lecture consisted of the basic concepts of the DIR method and play strategies. During each one-on-one session, the mother was trained in the home-based DIR/FloortimeTM intervention program for 2 to 3 hr and set individualized goals for her child. To achieve the identified goals, the mothers were trained to observe their child’s cues, follow the child’s lead, and implement the play strategies that were appropriate for their child’s current level of functional development.
FIGURE 1. The process of the DIR/FloortimeTM intervention program.
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At the beginning of the intervention program, each family received a manual to facilitate the application of play strategies to daily activities. The mothers were asked about their goals and discussed them with the first author. Specific goals and a home program were established according to the results of evaluation and children’s age and development for each family. The mothers were instructed to conduct the home-based DIR/FloortimeTM intervention program for at least 10 hr per week. In addition, the first author met with the mothers and children every 2 weeks to discuss concerns regarding the intervention program or difficulties experienced by the parents or children. All of the mothers completed the 10-week intervention program. The average number of intervention hours for all participants was 109.7 (SD = 38.0, [85–152]). Each child with ASD was instructed to continue his routine programs, including special or preschool education, speech therapy, or occupational therapy. Data Analysis SPSS 17.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze the data. Descriptive statistics were computed for demographic data, independent variables, and outcome measures. Wilcoxon-signed rank tests were performed to examine changes in the children’s emotional functioning and adaptive behaviors, as well as differences in the level of parental stress. The level of significance was set at p < .05. An effect size index r was established on the basis of the z score divided by the square root of the total sample (low effect size: 0.30 > r ≥ 0.10, medium effect size: 0.50 > r ≥ 0.30, large effect size: r ≥ 0.50; Cohen, 1988). RESULTS Functional Emotional Assessment Scale Mean scores for the overall FEAS and the six FEAS domains increased over the 10-week intervention (Table 2). The effect size for the total score was 0.49 and varied from 0.30 to 0.58 for the six domain scores (medium to large effect). Differences were significant for the total score (Z = −2.31, p < .05) and the domains engagement and relating (Z = −2.44, p < .05), two-way purposeful emotional interaction (Z = −2.70, p < .01), and social problem solving (Z = −2.50, p < .05). Vineland Adaptive Behavior Scales The effect size for the VABS-2 varied from 0.43 to 0.52 (medium to large effect) except for motor skills (0.21) (Table 2). There were significant improvements in the total score (Z = −2.19, p < .05) and the domains communication (Z = −2.02, p < .05), daily living skills (Z = 2.45, p < .05), and social (Z = −2.09, p < .05). Parenting Stress Index-Short Form The effect size was small for the change in total score (0.27) and subscale scores for parental distress (0.17) and difficult child (0.27). There was a significant (Z = −2.11, p < .05) decrease in the parent–child dysfunctional interaction score; the effect size was medium (0.45) (Table 3). The latter finding indicates that mothers perceived greater positive parent–child interactions following the intervention.
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TABLE 2. Changes in Functional Emotional Assessment Scale and Vineland Adaptive Behaviors Scales by Children with ASD
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Measure Functional Emotional Assessment Scale Total Score Self-regulation and interest in the world Forming relationships, attachment, and engagement Two-way, purposeful communication Behavioral organization, problem solving, and internalization Representational capacity Representational differentiation Vineland Adaptive Behavior Scale—second edition Total Score Communication Daily Living Skills Socialization Motor Skills
Statistics
Pretest M (SD)
Posttest M (SD)
p
Effect Size
30.6 (13.6) 10.5 (2.6) 7.4 (3.4) 4.2 (2.3) 1.6 (1.2)
39.8 (16.8) 11.9 (3.1) 10.6 (4.7) 5.7 (2.4) 2.5 (1.1)
< .05 0.12 < .05 < .01 < .05
0.49 0.33 0.52 0.58 0.53
5.0 (3.6) 2.1 (2.3)
6.0 (4.1) 3.1 (2.9)
0.28 0.16
0.23 0.30
154.3 (56.9) 43.5 (17.9) 52.4 (25.2) 21.2 (10.9) 37.3 (9.6)
173.5 (65.1) 48.0 (20.5) 60.7 (24.4) 25.8 (15.3) 38.9 (10.2)
< .05 < .05 < .05 < .05 0.33
0.47 0.43 0.52 0.45 0.21
DISCUSSION There are several limitations that are important to consider when interpreting the results. This was a single group design and, therefore, the effect of maturation and other services and supports were not controlled. In addition, the mothers’ were a sample of convenience who expressed interest in their children receiving additional services. They may not reflect the attitudes and beliefs of all mothers of young children with ASD. The results provide preliminary evidence of the effects that the home-based DIR/FloortimeTM intervention program have on increasing the social interaction and adaptive behaviors of children with ASD in Taiwan. This research provides three main findings. First, children made significant improvements in two-way purposeful communication, forming relationships, behavioral organization, and problem solving following the home-based DIR/FloortimeTM intervention program. The effect size varied from medium to large. Second, the adaptive functioning of the children improved, especially communication and daily living skills. The effect size varied from medium to large. Third, the mothers perceived positive changes in their parent–child interactions after implementing the home-based DIR/FloortimeTM intervention program. TABLE 3. Changes in Parenting Stress Index: Short Form by Children with ASD (n = 11)
Measures Total score Parental distress Parent–child dysfunctional interaction Difficult child
Statistics
Pretest M (SD)
Posttest M (SD)
p
Effect Size
106.9 (11.8) 37.3 (7.1) 32.6 (5.3) 37.1 (6.4)
100.0 (15.0) 35.9 (6.1) 30.0 (5.6) 34.1 (7.1)
0.21 0.41 < .05 0.20
0.27 0.17 0.45 0.27
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Consistent with the results of previous studies (e.g., Pajareya & Nopmaneejumruslers, 2011; Solomon et al., 2007), we found that training in the home-based DIR/FloortimeTM intervention program was effective for enhancing the development of children with ASD. In our study, the average total FEAS score increased from 30.6 to 39.8, a medium effect size. Our findings correspond to those of a similar to 3-month study conducted in Thailand (Pajareya & Nopmaneejumruslers, 2011). The intervention period in our study was shorter (10 weeks) and less intense (average of 10 hr per week) compared with Pajareya and Nopmaneejumruslers (average of 15.2 hr for 3 months). The results are encouraging because they suggest that interventions performed by mothers at home can be effective. Our results indicate that the children made significant gains in adaptive skills. Notably, many related studies (e.g., Klin et al., 2007; Szatmari et al., 2003) have focused primarily on the socialization and communication, and have overlooked the daily living skills (Jasmin et al., 2009). Few interventions have been designed to target daily living skills. In our study, children with ASD achieved functional improvements in their daily living skills over the 10-week intervention. Greenspan and Weider recommended that caregivers execute six to ten 20–30-min DIR/FloortimeTM interventions per day during play time and activities of daily living (Greenspan & Wieder, 1997). The home-based DIR/FloortimeTM intervention program developed in this study satisfied this recommendation and equipped mothers with strategies for cultivating children’s functional and developmental skills. In Chinese, the parent–child relationship is embedded in a hierarchical family structure. Interactions between parents and children are connected to the notion of parental control and governance (Wu, 2013). We observed that the mothers perceived improvements in their parent–child interactions after the intervention. The mothers in this study were taught how to play with their children in a natural environment. Many of the mothers reported that they did not know how to play with their child at the beginning of the study. By contrast, after completing the training, they were confident and eager to play with their children. These observations suggest the importance of collaboration with mothers of children with ASD on strategies for play. Nevertheless, no significant improvements in the subscales of Parental Distress or Difficult Child were observed. According to Abidin (1990), parental distress reflects complex aspects, including perceptions of child-rearing competence, conflict with a spouse or partner, social support, and stresses associated with restrictions placed on other life roles. The subscale Difficult Child reflects the caregiver’s view of a child’s temperament, noncompliance, and demands. Changes to these subscales might not be noticeable in a short intervention period. Several studies have suggested that mothers of children with ASD experience high levels of distress, and that the sources of parental stress are confounding factors (Mori et al., 2009; Tomanik et al., 2004). One possible explanation is that the intensive interventions and consultations support provided every 2 weeks in this study primarily focused on improving the interaction between parents and children and the acquisition of play skills. Accordingly, the mothers perceived substantial changes in their parent–child interactions. Further research is recommended to identify strategies for reducing parental distress related to behavioral problems of children with ASD.
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With respect to implications for practice, the results are useful for occupational therapists to assist mothers to carry out the home-based DIR/FloortimeTM intervention program for children with ASD in Taiwan. Therapists could involve mothers in direct treatment in order to coordinate center/hospital and home programs. Further research including randomized controlled trials is needed to substantiate the results of our study with greater number of participants. We could not control for the effects of normal development, and certain confounding factors (such as family environment, maternal personality traits, etc.). Consideration should be given to including covariates such as severity of ASD symptom and mothers’ wellbeing and interactions when analyzing outcomes. CONCLUSION This study provides preliminary evidence of the effectiveness of a 10-week home-based DIR/FloortimeTM intervention program for preschool age children with ASD and their mothers. Children made significant improvement in emotional functioning including two-way communication, behavioral organization, and relationship forming. Furthermore, their adaptive functioning improved, especially in communication and social skills. Further research, including randomized controlled trials, are recommended to determine the effectiveness of DIR/FloortimeTM intervention program in improving social interaction and adaptive behaviors of preschool children with ASD. ACKNOWLEDGMENTS Support for this research was provided by the Taiwan Ministry of Education under the NCKU Aim for the Top University Project for Promoting Academic Excellence & Developing World Class Research Centers. We thank all the families that participated. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. ABOUT THE AUTHORS Shu-Ting Liao, M.S., Yea-Shwu Hwang, Sc.D., and Ling-Yi Lin, Sc.D., Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan. Yung-Jung Chen, M.D., DMSci, Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. Peichin Lee, Ph.D., School of Occupational Therapy, Chung Shan Medical University, Taichung, Taiwan. Shin-Jaw Chen, M.D., Dr. Yin’s Clinic, Tainan, Taiwan REFERENCES Abidin RR. (1990). Parenting stress index/short form. Lutz, FL: Psychological Assessment Resources. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Association.
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