Intensity Matters???

Historically, theorists, researchers, and practitioners alike have often presented that the intensity of therapy and therapeutic interactions for autistic children needed to be very high in order to get results.  While there is logic behind this guidance, we have been getting more information of late that the intensity may not need to be what we once thought. Nor may it need to be what therapy centers owned by equity firms may want it to be. 

What have we been learning?  Well, here is some information for consideration:

• Some DIRFloortime studies like the Solomon et al. (2014) and Pajareya et al. (2019) utilized around 12 hours a week and saw positive results.
• Rogers et al. (2021) compared 25 hours of ABA and ESDM to 15 hours and saw no significant difference in outcomes.  
• There isn't robust evidence that the benefits of early childhood interventions to young autistic children increase when those interventions are intensified (Sandbank et al., 2024).
• Autistic self-advocates are stressing that an autistic child needs time to be a child and everything the child is doing should not be therapy.  This can be seen in the Autistic Self-Advocacy Network’s For Whose Benefit?: Evidence, Ethics, and Effectiveness of Autism Interventions.
• Money may be a motivator for advocating for high intensity services.  You can read a telling article on the topic of equity firms that own therapy centers by clicking here. 
  

What do we get when we add up this emerging information?  We get an understanding that the high level of intensity that we once thought was needed, may not be needed.  In addition, when you consider the feedback from self-advocates, being in therapy all the time may also have negative consequences for the well-being of the child.  

In DIRFloortime practice, and in most of the studies that have been conducted on DIRFloortime, the hours of professional therapy is actually quite low.  Often it is about 2 hours a week or less.  The additional 12 to 20 hours that has been studied are therapeutic interactions provided by the caregivers.  

20 hours a week can be a lot for both the child(ren) and the caregiver(s).  Based on the emerging research and perspectives from autistic self-advocates, it seems we need to modify the old recommendation and adjust our recommendations to be about 12 hours a week instead of 20 or more.  It may be that we don't even need to get to 12, but there is no clear research to show how beneficial less than 12 is for autistic children.  Nevertheless, I have talked to many families that cannot get to 12 hours a week and they still have seen wonderful positive progression for there child when they utilize DIRFloortime.  

Part of it may not just be the implementation of DIRFloortime.  It may also be the embedding of DIR into the family culture.  For example, embedding a respectful and joyful focus on helping the children in the family grow and development in the context of their own authentic selves instead of fixing them or trying to make them look neuortypical may be as valuable as the actual therapeutic techniques that are used. 

Bottom line: What I always tell families is to go for 12 hours if you can.  See if you can get there. But remember, it all starts with one, and one is better than none!