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!
When my son was diagnosed with Asperger syndrome in 1996, almost everybody who had a child with the diagnosis was doing 40 hours a week of ABA therapy. My three-year-old son was already getting private therapy in speech and he was in a therapeutic preschool for half a day five days a week. He also still took an afternoon nap. I didn’t think a three year-old should do 40 hours a week of anything. I don’t remember how we found floor time but we did. We learned it from Stanley Greenspan’s book about the special needs child. My husband and he played with Thomas the Tank Engine trains a lot using the floortime approach. It makes sense because it’s a social approach and the core difference in the autism spectrum is social understanding, understanding other people. Most of the skills we want to develop in our children are not behaviors, but skills. You need therapy to develop skills. You don’t develop language using behavior you need a speech therapist. You don’t develop fine motor skills and learn to tolerate sensory issues with behavior. You learn it with occupational therapy. And you can’t learn to be social using behavior because being social is a skill. I estimate that he received about 12 hours a week of therapy from the formal settings. We probably did one to two hours a day at home of floor time. My son is now 31, he drives, he takes care of all his food and clothing needs, and he has a full-time job. He navigates the world very well and his problem-solving skills are fantastic. If we had done, ABA, he would’ve become a behavior problem. I completely agree that less is more, and they need time to decompress and recover from the effort it takes to be social. If a child is verbal and able to engage with a person, floortime is a much better intervention than ABA.
ReplyDeleteYour story sounds exactly like mine. My now 31 year old son was dx with PDD when he was almost 3. The preschool CST recommended we put him in the full day ABA class but we rejected that and he attended the 1/2 day preschool class and got speech and OT there. By K, he was mainstreamed into a gen ed class with an IEP and a classification of Autism. By his senior year in high school, he was in several AP classes and was the editor of the school's literary magazine. He graduated from a prestigious liberal arts university out of state and now lives independently and has a very good job. Had he received ABA as suggested by the CST, his path would most certainly have been very different.
ReplyDeleteHow much time should kids spend regulated, attentive, and engaged in meaningful interactions with manageable challenges thrown in (when they are ready)?
ReplyDeleteI don't think there is any magic number or amount. The starting place I always use for any recommendations for things like this is "balance". The best place to start in most cases is a balanced approach. Of course, every situation is unique and the exacts plans need to be based on the particular child.
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