When Being Nice to Children Becomes a Definition of Therapy: A Problem with DRBI
Why the proposed definition of Developmental Relationship-Based Interventions raises serious questions about developmental science, professional competency, and evidence-based practice.
This morning I have been attending sessions of the International DIRFloortime® Conference that have moved me to finalize the following post and to get it out to all of you. The presentations have highlighted the depth of DIR® and how there is so much more to DIRFloortime® than a list of techniques. The first two presentations this morning went further to show how the use of DIRFloortime techniques without fully understanding the full depth of DIR, can potentially be harmful. This relates to my concerns about the newly proposed category of Developmental Relationship Based Interventions (DRBI).
There is a troubling development emerging in the field of autism services, and I believe it is time to challenge it directly. A group of researchers and clinicians, led by Diane Cullinane, published a position paper in 2024 proposing a category called Developmental Relationship-Based Interventions (DRBI). The authors suggest that this category can help distinguish developmental approaches from behavioral approaches and bring greater clarity to research, clinical practice, and policy. On the surface, this seems like a reasonable goal, and I certainly appreciate the desire to recognize developmental approaches as distinct from behavioral approaches. However, I have serious concerns about the definition they have proposed, the process through which it was developed, and the implications of treating this proposed category as though it represents an established scientific standard.
I believe the definition is so limited that it risks reducing developmental therapy to a handful of positive adult-child interaction strategies, without adequately addressing the comprehensive developmental understanding and professional competencies necessary to provide meaningful developmental services. This becomes particularly concerning when we consider how the category may be used by organizations, providers, researchers, and policymakers to make claims about evidence-based practice.
First, Let's Be Clear About What This Paper Actually Is
The 2024 publication by Cullinane and colleagues is explicitly identified by the journal as a position paper. That distinction matters, especially as the proposed DRBI category begins appearing in discussions about research, professional practice, and public policy.
A position paper presents the perspectives, interpretations, and recommendations of its authors. Position papers can make important contributions to professional discussions, and I have no objection to a group of people coming together to propose a new way of organizing or understanding a field. However, we should be very careful about confusing a position taken by a group of professionals with a conclusion established through rigorous scientific investigation.
In this case, the authors describe a process in which a group of individuals from several professional disciplines and countries was assembled to discuss developmental approaches. The group evolved organically, largely through email exchanges, and developed a shared position regarding what they considered to be the defining characteristics of developmental interventions. The authors also reviewed selected developmental intervention literature and identified common strategies among several approaches.
That is a legitimate way to develop a professional position. However, the paper does not report a systematic review conducted under a prespecified protocol, a formal consensus methodology, or empirical validation of the proposed DRBI classification. The authors do cite empirical research supporting several specific developmental approaches, but that research does not independently establish the validity of the broader category they propose.
This is an important distinction. The paper draws upon scientific literature, but the proposed definition of DRBI is itself a position advanced by the authors, not a scientifically validated classification.
I also find it concerning that a relatively small group of individuals can propose a classification with potentially significant implications for an entire field, without a more comprehensive process involving the many professionals, organizations, researchers, autistic individuals, and families who would be affected by its adoption. I am not suggesting that every professional position requires universal agreement. However, the breadth of participation and rigor of the process should be considered when determining how much authority to give the resulting recommendations.
We should welcome professional opinions and thoughtful proposals, but we should also be willing to challenge them. A position paper does not become scientifically established simply because its authors may be respected professionals, it cites research, or it appears in a peer-reviewed journal. We also need to be willing to challenge the positionality of the authors and openly acknowledge potential conflicts of interest.
Four Strategies Do Not Make a Developmental Therapy
In their position paper, Cullinane et al. identify two defining features of DRBI: the use of a developmental framework that emphasizes a child's intrinsic motivation for social engagement and learning, and a focus on relationships and interactions. They then identify four common strategies that they believe characterize developmental relationship-based interventions:
- Social play
- Sensitive responding
- Following the child's lead
- Presenting challenges
These are all valuable strategies, and I would expect them to be present in many developmentally supportive interactions. However, I find it difficult to understand how these relatively general characteristics could serve as an adequate foundation for defining a category of developmental therapy, particularly one intended to influence clinical practice, research, and public policy.
Being playful, responsive, and attentive to a child's interests are certainly important qualities. So is knowing how to introduce appropriate challenges. But these characteristics tell us very little about the developmental knowledge guiding a practitioner's decisions. They do not establish whether someone understands sensory processing, motor planning, affect, emotional regulation, communication, cognitive development, or the complex interactions among biological, psychological, and social systems. They also do not establish whether a practitioner understands how developmental capacities emerge and become increasingly complex, or how individual differences influence the ways children experience and engage with the world.
Perhaps most importantly, these strategies do not tell us whether a practitioner has the knowledge and competencies necessary to recognize a child's developmental capacities, understand the meaning of their behavior, or make informed decisions about how to support their continued development.
The authors certainly discuss developmental theory and individual differences elsewhere in the position paper, and I do not want to suggest otherwise. My concern is that the proposed defining characteristics are insufficiently developed to establish meaningful standards for developmental practice. Describing a general developmental orientation and identifying four common strategies leaves unanswered some of the most important questions about what actually constitutes competent developmental therapy.
Let's Take This Argument Somewhere Uncomfortable
I want to introduce a comparison that some people may find disturbing, but I believe it illustrates an important problem with relying on outwardly positive interaction strategies to characterize therapeutic practice.
Some of you may know that a good part of my career has included work in child welfare and supporting children that have been abused and experienced the intense ramifications of interpersonal abuse. This is why the following comparison is very meaningful to me and I hope I can show how and why.
Consider what we know from research on child grooming and interpersonal abuse. One of the most troubling realities of child exploitation is that individuals who manipulate and abuse children may initially appear extraordinarily kind, attentive, playful, and responsive. They may take a special interest in a child's favorite activities, follow the child's interests, respond to emotional needs, and gradually introduce challenges or requests. These interactions may initially feel positive to the child, even though the adult's underlying intentions and subsequent actions can be profoundly harmful.
Research on grooming has documented how trust, attention, affection, and apparently supportive interactions can be manipulated to facilitate exploitation. This does not mean that the four strategies identified in the DRBI position paper are themselves abusive, nor does it mean that the paper endorses harmful practices. Rather, it illustrates why we cannot determine the quality, appropriateness, or therapeutic value of an interaction simply by observing whether certain positive interaction strategies are present.
Consider the following comparison:
|
Interaction Strategy |
Developmentally Supportive Application |
Potentially Harmful Application |
|
Social Play |
Builds connection, joy, exploration, and shared meaning. |
Can be used to manipulate trust, cross boundaries, or normalize inappropriate interactions. |
|
Sensitive Responding |
Recognizes emotional experiences and supports regulation and well-being. |
Can be used to identify vulnerabilities and exploit emotional needs. |
|
Following the Child's Lead |
Supports autonomy, agency, initiative, and meaningful participation. |
Can create the appearance of autonomy while subtly manipulating the child's choices. |
|
Presenting Challenges |
Supports problem-solving, creativity, and expanding developmental capacities. |
Can become coercive, overwhelming, or a means of gradually normalizing boundary violations. |
I recognize that this is an extreme comparison, and I am intentionally using it to make a point. The presence of positive interaction strategies does not, by itself, establish that an interaction is healthy, developmentally appropriate, ethical, or therapeutic. We must consider the underlying purpose of the interaction, the developmental understanding guiding it, the competencies of the adult, and the actual experiences and outcomes for the child.
If we can recognize how seemingly positive interactions can be used in profoundly harmful ways, we should certainly be able to recognize why these same observable strategies cannot be sufficient to define competent developmental therapy.
Being Good with Children is Good, But It Does Not Make Someone a Developmental Therapist Or Good Parent Coach
We do not need to consider extreme examples to recognize the limitations of this proposed definition. Think about a wonderful preschool teacher who is playful, responsive, follows children's interests, and knows how to introduce challenges that encourage exploration and learning. Or consider a loving parent, a grandparent, or a camp counselor who demonstrates these same qualities. All may be doing wonderful things that support children's development, and in some cases, they may be exceptionally skilled at creating the kinds of interactions that help children thrive.
However, we would not automatically conclude that they are providing professional developmental therapy simply because they demonstrate these four strategies.
This is where I believe the proposed DRBI classification becomes particularly problematic. There is an important distinction between supporting development through everyday interactions and providing professional services grounded in a comprehensive understanding of human development. The distinction involves knowledge, professional reasoning, competency, assessment, and an understanding of how to individualize practice to support meaningful developmental growth.
A practitioner who is warm, playful, and responsive may still lack the knowledge to recognize significant sensory or motor challenges, understand differences in emotional regulation, identify developmental capacities, or appreciate how affect influences learning and communication. A practitioner may also be exceptionally skilled at engaging children while having very little understanding of the developmental processes they are attempting to support.
If we are going to define a category of developmental therapy, should we not be establishing what practitioners must understand about development, rather than primarily describing how they should interact with children?
Where Is the Development in DRBI?
The word developmental is central to the proposed DRBI category, yet I believe the position paper leaves significant questions unanswered about what that designation should actually require.
Human development is extraordinarily complex. It involves the ongoing interaction of biological, neurological, psychological, emotional, social, and environmental processes. Understanding development requires far more than recognizing that children have an intrinsic motivation to engage with the world or that supportive relationships are important.
A meaningful developmental framework should inform how we understand the whole person, how we recognize developmental capacities, how we consider individual differences, and how we make decisions about supporting growth. It should also provide a coherent explanation of why particular practices are appropriate and how those practices are expected to support development.
For example, I believe any credible definition of developmental therapy should be able to address questions such as:
- What comprehensive developmental theory or framework guides the practice?
- How are functional emotional developmental capacities understood and assessed?
- How are sensory processing, motor planning, affect, communication, cognition, and other individual differences considered?
- What informs decisions about when to support regulation, expand an interaction, introduce a challenge, or modify expectations?
- How are the individual's agency, autonomy, and emotional experiences respected?
- What developmental outcomes are being supported, and how are they evaluated?
- What education, training, and demonstrated competencies are necessary to provide the services?
- How is fidelity to the underlying developmental framework established?
These questions should not be treated as secondary considerations. They go to the heart of what it means to provide developmental services.
Without adequate answers, we risk creating a category that describes certain desirable interaction styles without sufficiently defining the developmental understanding necessary to guide them.
DIR Is a Comprehensive Developmental Framework
This is one reason I believe it is important to distinguish DIR® from the proposed DRBI classification.
DIR is a comprehensive, transdisciplinary framework for understanding human development. The D represents Developmental, the I represents Individual Differences, and the R represents Relationship-Based. These are not three independent ingredients that can simply be combined to create a developmental approach. They represent an integrated understanding of how development occurs through the continuous interaction of individual biological and neurological differences, affective experiences, relationships, and the broader environment.
DIR recognizes functional emotional developmental capacities, the profound influence of individual differences, and the essential role of affect and relationships in supporting human development. DIRFloortime is a practice guided by that framework.
A skilled DIRFloortime practitioner certainly uses play, follows the individual's lead, responds sensitively, and introduces developmentally appropriate challenges. However, the practitioner is also continuously considering the individual's developmental capacities, sensory and motor profile, emotional experiences, communication, intentions, and ways of engaging with the world. These considerations inform how the practitioner understands the interaction and determines what might best support the person's continued development.
Two practitioners might appear to be doing exactly the same thing on the surface while operating from fundamentally different understandings of the child and pursuing very different developmental goals. This is why simply observing particular interaction strategies tells us relatively little about the developmental framework guiding the practice.
The professional education and competency standards associated with DIRFloortime are intended to develop this depth of understanding. They reflect the recognition that effective developmental practice requires more than a set of techniques. It requires the ability to understand and apply a comprehensive developmental framework in ways that are responsive to the individual.
I would also emphasize that DIR is not simply a childhood autism intervention. It is a framework for understanding human development across the lifespan and across a wide range of developmental, educational, clinical, and everyday contexts. Reducing it to a category of interventions for autistic children risks overlooking much of what makes DIR a comprehensive developmental framework.
The Evidence-Based Problem is Very Concerning
Beyond the conceptual limitations and lack of rigor of the proposed definition, I am increasingly concerned about how the DRBI category may be used to make claims about evidence-based practice.
The Cullinane et al. position paper cites research involving several established approaches, including DIR, PACT, JAML, Responsive Teaching, and iBASIS-VIPP. These approaches have their own theoretical foundations, practice models, professional preparation requirements, and research histories. Some have been evaluated through randomized controlled trials, and others have additional forms of research supporting particular practices and outcomes.
However, the research supporting these specific approaches does not automatically establish that DRBI is itself an evidence-based treatment model. Nor does it establish that any organization or practitioner adopting the DRBI label is providing services consistent with the approaches that have actually been studied.
This is where the distinction between a position paper and empirical research becomes especially important. The authors have proposed a classification based on their interpretation of common characteristics among selected approaches. That classification has not, by virtue of publication, become an independently validated treatment model with an established evidence base.
I am concerned that some organizations may begin using the DRBI designation as though it provides a scientific endorsement of their services, even when those services are not clearly connected to a defined developmental framework, established professional competencies, or research evaluating the actual practices being delivered.
This raises significant questions for families, researchers, insurance companies, and policymakers. If an organization advertises that it provides evidence-based DRBI services, what exactly does that mean? Is it delivering one of the established approaches cited in the position paper? Has it developed its own model? What research supports that model? What professional education and competency standards apply? How is fidelity assessed?
We cannot simply take research conducted on DIRFloortime, PACT, or another established approach and use it to validate whatever services an organization chooses to describe as DRBI. Evidence supporting specific practices must be understood in relation to those practices, their theoretical foundations, their implementation, and the outcomes actually studied.
I believe this issue becomes particularly serious when we consider the potential use of DRBI in insurance coverage, government funding, professional qualifications, and regulatory policy. A loosely defined category could create opportunities for providers to claim scientific legitimacy without demonstrating the training, competency, or fidelity that families should reasonably expect.
That is a risk we should be addressing before the category becomes widely institutionalized, rather than after. This is one of the reasons we are not simply supporting the adoption of this category as proposed.
Even the Word "Intervention" Deserves Some Reflection
There is another aspect of this discussion that I believe warrants consideration, and it involves the language we use to describe our work.
The proposed DRBI category is organized around the word intervention. I understand why that terminology is used. Families are looking for interventions that can help their children, professionals provide interventions, researchers study interventions, and insurance systems reimburse interventions. I am not suggesting that we abandon the term or disregard the very real support that individuals and families are seeking.
However, I do believe that our language can influence how we conceptualize the purpose of developmental services. From a DIR perspective, our primary focus is on understanding and supporting human development, learning, agency, participation, and well-being. An intervention may be one means of providing that support, but it is not the developmental framework itself, nor should the intervention become the central purpose of our work.
Autistic children and children with other neurodevelopmental differences are developing human beings with individual strengths, capacities, interests, challenges, and ways of experiencing the world. Our responsibility is to understand the whole person and support meaningful growth and development in ways that respect their individuality.
This is a broader and, I believe, more appropriate starting point for understanding developmental practice than organizing our work primarily around categories of intervention strategies.
We Need Better Standards, Not Broader Labels
I want to be clear that ICDL is not opposed to creating categories that help distinguish developmental approaches from behavioral approaches. In fact, I believe meaningful distinctions are essential, and I welcome efforts to improve how developmental perspectives are understood in research, clinical practice, and policy.
However, a category must be sufficiently well-defined to serve its intended purpose. It should help families understand the services they are receiving, help researchers identify approaches that are meaningfully comparable, and help policymakers establish standards that reflect the actual knowledge and competencies required for quality practice.
I do not believe the current proposed DRBI definition adequately accomplishes these goals.
The Cullinane et al. position paper represents the perspectives of a relatively small group of professionals who have proposed a way to classify certain developmental approaches. Their perspectives deserve consideration, but they also deserve critical examination, particularly given the implications of the proposed classification.
There is nothing inherently wrong with proposing a new category through a position paper. The problem arises when a proposed category begins to be treated as an established scientific standard without the additional research, validation, professional dialogue, and careful definition necessary to support that level of authority.
I would welcome a much broader discussion about how developmental approaches should be understood and classified, including meaningful participation from autistic individuals, families, professionals across disciplines, developmental researchers, and organizations representing established developmental frameworks.
That discussion should begin with a comprehensive understanding of human development and should take seriously the knowledge and competencies required to support it.
And if you want a real-life example of the concern, several of the authors are a part of an upcoming conference in 2027 on DRBI approaches and suddenly they have added at least four more approaches that are not included in their position paper and do not necessarily have adequate research to support being in such a category. I find this to be professionally irresponsible. It is manipulating a position paper into an umbrella that now has approaches that may have little to no peer reviewed research behind them under that umbrella. I fear that professional irresponsibility, even if not intentional, may be dangerous and undermine the hard work people have put into creating credibility for DIRFloortime and other legitimate developmental approaches.
Relationships Matter, But They Are Not Enough
I have spent much of my professional career advocating for the importance of relationships, affect, individual differences, and developmental understanding. I believe strongly that meaningful human connections are central to development and well-being, and I appreciate the efforts of those who seek to move our field toward more respectful, developmental, and relationship-based practices.
However, we do a disservice to the very principles we are trying to advance when we reduce developmental practice to a small collection of interaction strategies. Relationships are essential, but simply being in a relationship, even a positive and supportive one, does not establish that someone understands human development or is qualified to provide developmental therapy. The complexity of human development deserves far more consideration than that.
I also believe we have a responsibility to challenge the growing tendency to use terminology that sounds scientifically credible without ensuring that the underlying practices meet meaningful professional and scientific standards. Families should not have to navigate a system in which almost anyone can claim to provide an evidence-based developmental approach simply because they use play, respond sensitively, follow a child's lead, and present challenges. Those strategies may be important, but they cannot substitute for a comprehensive developmental framework, appropriate professional preparation, demonstrated competency, and accountability for the services being provided.
My concern with the Cullinane et al. position paper is not that its authors value relationships or seek greater recognition for developmental approaches. I share those goals. My concern is that their proposed definition is inadequate for the purpose they intend it to serve, particularly if it is going to influence how developmental services are classified, researched, funded, and delivered. The fact that a group of professionals has published a position does not mean the field should simply accept it. Scientific and professional progress requires us to examine assumptions, question conclusions, and remain open to the possibility that even well-intentioned proposals may be fundamentally flawed.
At ICDL, we believe that developmental perspectives have much to contribute to how we understand and support autistic individuals and others with neurodevelopmental differences. We also believe that the field needs greater clarity about the distinctions between developmental frameworks, professional practices, and specific intervention models. We welcome serious efforts to advance that discussion, and we are certainly not suggesting that DIR, as the leading developmental approach, is the only legitimate developmental framework. However, whatever categories we develop must reflect the complexity of human development and the knowledge required to support it.
Ultimately, this is about much more than terminology. It is about the integrity of developmental practice, the credibility of the research we use to support it, and the responsibility we have to the individuals and families who place their trust in professionals.
If we are going to call something developmental therapy, we should be able to explain what makes it developmental, what makes it therapeutic, what knowledge and competencies are required to provide it, and what evidence supports the actual practices being delivered.
I do not believe the current DRBI definition adequately answers those questions, and I do not believe the field should accept a position paper as sufficient justification for adopting a classification with such significant implications.
We can and should do better. The people we serve deserve nothing less.
DIR® and DIRFloortime® are registered trademarks of the International Council on Development and Learning (ICDL), the home of DIR® and DIRFloortime®
Cullinane, D. A., Binns, A. V., Feder, J. D., Graham, T., Mahoney, G. J., Naber, F. B. A., Robinson, R. G., Schertz, H. H., Solomon, R. M., Whitehouse, A. J. O., & Wieder, S. (2024). Developmental relationship-based interventions for autistic children. Topics in Early Childhood Special Education. https://doi.org/10.1177/02711214241303695
