If your child has been diagnosed with autism, you’ve almost certainly been presented with ABA therapy as the primary — and sometimes only — recommended option. But there’s another evidence-based approach with decades of clinical research behind it: The Greenspan Floortime Approach®. This isn’t a takedown of ABA. It’s an honest look at how these two approaches differ, and why more families are choosing — or adding — Floortime to their child’s program.

What Is ABA Therapy?

Applied Behavior Analysis (ABA) is a therapy approach rooted in behavioral psychology. It uses structured reinforcement to teach specific skills and reduce unwanted behaviors. ABA is widely prescribed for autism and is often covered by insurance. ABA can be effective at teaching discrete skills — toileting, following directions, reducing self-injurious behavior. Many families have found value in ABA when implemented with warmth and flexibility.

What Is the Greenspan Floortime Approach®?

The Greenspan Floortime Approach® is a relationship-based, developmental therapy developed by Dr. Stanley I. Greenspan. Rather than targeting specific behaviors, it builds the underlying developmental foundations — emotional connection, communication, problem-solving, and creative thinking — through child-led, joyful play. Floortime is rooted in the Greenspan/DIR model, which looks at the whole child: their developmental level, their individual sensory and processing differences, and the relationships that drive their growth.

The Core Difference: Behavior vs. Development

• ABA focuses on what a child does — and uses reinforcement to shape those behaviors toward desired outcomes.
• The Greenspan Floortime Approach® focuses on who a child is developmentally — and builds genuine emotional and cognitive capacities from the inside out.

Dr. Greenspan’s view was that a child who learns to comply with demands hasn’t necessarily developed the internal emotional architecture needed for genuine relationships, flexible thinking, and self-directed learning. Floortime aims to build that architecture first.

Can You Do Both?

Many families do. ABA and Floortime are not mutually exclusive. Some families use ABA for specific skill-building while incorporating Floortime principles at home to deepen connection and emotional development. Others transition away from ABA as their child progresses with Floortime. The most important thing is that your child’s program is built around their individual developmental needs.

What Does the Research Say?

Dr. Greenspan’s approach is supported by peer-reviewed research showing significant gains in communication, emotional functioning, and overall development for children with autism. His landmark studies documented children making developmental progress previously thought impossible.

Learn More About The Greenspan Floortime Approach®

Whether you’re just starting to explore your options or looking to complement your child’s current program, stanleygreenspan.com has everything you need — including Dr. Greenspan’s Parent Course, The Floortime Manual 2nd Edition, and Ask Stanley AI for personalized guidance. Explore resources at stanleygreenspan.com

Frequently Asked Questions

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If your child has received a diagnosis of autism, developmental delay, or sensory processing differences, you’ve likely heard the term DIR or DIR/Floortime. But what does DIR actually mean — and why does Dr. Greenspan’s version, The Greenspan Floortime Approach®, stand apart from other developmental therapies? Here’s a plain-language breakdown.

What Does DIR Stand For?

DIR stands for Developmental, Individual Differences, and Relationship-based. It’s a comprehensive framework developed by Dr. Stanley I. Greenspan that looks at the whole child — not just behaviors or symptoms.

D — Developmental

The D refers to the six Functional Emotional Developmental Levels (FEDLs) that Dr. Greenspan identified as the foundation of all human learning and growth. These range from basic self-regulation and engagement all the way to abstract, logical thinking. Unlike approaches that target isolated skills, the Greenspan/DIR model asks: Where is this child developmentally, and how do we build from there?

I — Individual Differences

The I recognizes that every child processes the world differently. This includes sensory processing — how the brain handles sound, touch, movement, and visual input — motor planning, and auditory processing. A child who covers their ears isn’t being difficult. A child who crashes into furniture isn’t being reckless. They’re communicating through their nervous system. Once you understand your child’s individual differences, you can work with them instead of against them.

R — Relationship-Based

The R is the heart of the entire framework. All development — including academic, social, and emotional development — happens through warm, trusting relationships. The therapeutic relationship between parent and child is not just a vehicle for learning. It IS the learning. This is why The Greenspan Floortime Approach® centers parents as primary agents of their child’s development.

How the DIR Model Differs From Behavioral Approaches

Many autism therapies focus primarily on behavioral outcomes — teaching specific skills, reducing unwanted behaviors, or building compliance. The Greenspan/DIR model takes a fundamentally different view:

• Behavioral approaches ask: What does the child do, and how do we change it?
• The Greenspan/DIR model asks: Where is the child developmentally, and what do they need to grow?

The goal isn’t compliance — it’s genuine developmental growth. Children who progress through the DIR framework develop the internal emotional and cognitive tools they need for life, not just for a therapy setting.

Who Is the DIR Model For?

The Greenspan/DIR model was originally developed for children with autism spectrum disorder, but it has been applied successfully with children experiencing language delays, sensory processing disorders, ADHD, anxiety, Down syndrome, and other developmental conditions. The principles of the DIR framework support healthy development in all children — not just those with diagnoses.

Learn the Full Framework

The All Access Pass at stanleygreenspan.com gives you Dr. Greenspan’s complete library — including the Parent Course, Ask Stanley AI, all his books, and a certificate of completion in The Greenspan Floortime Approach®. Explore the All Access Pass at stanleygreenspan.com

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Due to class action lawsuits that have been filed, there is tremendous interest, especially by parents, in the relationship of autism and Tylenol. We are not lawyers and have no opinion on lawsuits.

That noted, we are experts at treating autism and other developmental delays in children and adults. So, as an aid to parents and other autism therapy professionals, we have developed this guide to understanding the ongoing published peer-reviewed research on autism and Tylenol. We will continuously update this autism and Tylenol research guide as further studies are published.

What is Tylenol?

Tylenol is a brand name for the drug commonly known as acetaminophen in the United States and Canada and known as paracetamol in the rest of the world. Chemically, it is N-acetyl-p-aminophenol and is sometimes referred to in academic journals as APAP. The name Tylenol comes from its chemical name (aceTYL-p-aminophENOL).

Back in 1884 Germany, two physicians used acetanilide, a derivative of aniline, a compound that had been isolated from coal tar and used in the production of the novel synthetic dyes that were all the rage, to treat a patient with a raging fever and intestinal worms. Acetanilide did nothing for the worms but did reduce the fever. They began marketing acetanilide as Antifebrin (medical-speak for anti-fever).

They would soon learn acetanilide’s nasty methemoglobinemia side-effect when the skin color of users turned a blueish color because of its inhibition of oxygen transport by hemoglobin. This led to a search for a way to make acetanilide safer by modifying its molecular structure to remove this nasty side-effect.

In 1887, the German pharmaceutical company Bayer did just that, producing phenacetin. That same year a Johns Hopkins chemistry professor, Harmon Morse, synthesized acetaminophen, which accomplished the same thing, but physicians at the time wrongly reported that it could sometimes still produce that nasty methemoglobinemia side-effect. Consequently, acetaminophen was shelved until 1947 when it was discovered that both acetanilide and phenacetin actually convert to acetaminophen in the body and that acetaminophen is the active fever-reducing compound in both drugs.

About Autism and Floortime Therapy

When a parent or caregiver hears the words “Your child has autistic spectrum disorder” from a psychologist or physician, it can often sound to that parent or caregiver like a life sentence. They believe that their child will always be autistic. That autism diagnosis, however, is dynamic not static.

What does it mean that your child’s diagnosis is dynamic? It means that it can change. Dr. Stanley Greenspan says that an autism diagnosis is dynamic. Floortime therapy can help in the development of children with autism spectrum disorder diagnoses.

There were three key developments in Dr. Greenspan’s research on children with autism and other developmental issues. The first of these is the importance of affect and relationships for the growth of the brain and mind. The second is the recognition that there are significant variations in the underlying processing capacities of children. The third is the recognition of what the integrated early stages of development actually are. You can learn more about Floortime therapy at our introduction to Floortime.

Associating Tylenol with Safety for Children and Pregnant Moms

Whereas Floortime is an autism treatment for children after they are born, the autism and Tylenol connection happens before the child is born. Why is this? This connection happens because for many years, and unlike aspirin and ibuprofen, Tylenol, including generic forms of acetaminophen or paracetamol, was considered a safe pain killer and fever reducer during pregnancy. After all, around 20% of the adult American population uses products containing Tylenol each week.

Tylenol has been considered the safest over-the-counter option for pregnant mothers. For years, its use within the recommended dosage was not thought to be harmful to developing in utero children. That view has more recently begun to change. Nevertheless, Tylenol and its generic formulations are among the most commonly used medications during pregnancy across the planet.

Why does acetaminophen have such a strong association with safety compared to other analgesics? Recall that phenacetin, discussed in the ‘What Is Tylenol?’ section above, was used instead of acetaminophen during the first half of the twentieth century. Phenacetin was eventually found to be associated with developing kidney problems. Another alternative, aspirin, was associated with stomach irritation and with Reye’s syndrome, a rare but serious children’s disease.

In the Spring of 1955, McNeil Laboratories launched TYLENOL Elixir for Children with acetaminophen as the active ingredient. McNeil Laboratories marketed Tylenol to physicians as a prescription-only safer alternative to aspirin and phenacetin. Their marketing campaign was wildly successful. The global acetaminophen market is now worth about $9.5 billion. In America, it’s estimated that about 65% of pregnant women use acetaminophen. It is the most commonly used over-the-counter medicine used during pregnancy.

Autism and Tylenol Research

This widespread commonality of Tylenol usage across the globe shapes our understanding of research findings about autism and Tylenol. It means that because Tylenol (acetaminophen or paracetamol) is used so much during pregnancy, even a small effect size on autism from using Tylenol will have significant effects on autism rates globally.

Autism and Tylenol Research Study 1: Paracetamol use during pregnancy–a call for Precautionary Action

We will begin with the 2021 Consensus Statement “Paracetamol use during pregnancy–a call for precautionary action” published in the prestigious scientific journal Nature Reviews Endocrinology. Unlike the other papers, this is not primary or scholarly medical research. This is a set of recommendations by 91 medical experts based on scholarly medical research. It’s a good starting point for us because it helpfully summarizes the meaning and implications of recent research findings.

Their assertion is that even though the FDA has long considered Tylenol safe for use during pregnancy, increasing experimental and epidemiological research suggests that prenatal exposure to acetaminophen increases the risks of neurodevelopmental, reproductive and urogenital disorders in children. For our purposes, we will focus on the neurodevelopmental risks.

Observational studies in kids suggest an association between prenatal exposure to acetaminophen and increased risk of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), language delay in girls, and decreased intelligence quotient (IQ). Experimental studies in animals have found that fetal exposure to acetaminophen induced brain changes that affected cognitive function, behavior, and even movement. These effects depend on the timing, duration, and dosage of prenatal acetaminophen exposure.

These medical experts recommend that pregnant women be given the following advice:

1. Forego using acetaminophen unless medically indicated.
2. Consult with their doctor if they are uncertain if using acetaminophen is indicated and before using on a long-term basis.
3. Minimize risk by using the lowest effective acetaminophen dose for the shortest possible time.

Autism and Tylenol Research Study 2: Association of cord plasma biomarkers of in utero acetaminophen exposure with risk of attention deficit/hyperactivity disorder and autism spectrum disorder in childhood

This important 2020 study that the National Institutes of Health (NIH) funded measured the amount of acetaminophen found in the umbilical cord blood of 996 births. These researchers wanted to find out whether the amount of acetaminophen found within that umbilical cord blood was associated with a diagnosis of ADHD or autism by the time these children reached 9 years of age. They classified the children by the amount of acetaminophen within their umbilical cord blood into three groups–lowest, middle, and highest.

Compared to the lowest third, kids in the middle third for acetaminophen concentration were at 2.26 times the risk for ADHD and 2.14 times the risk for autism. Kids in the highest third for acetaminophen concentration were at 2.86 times the risk for ADHD and 3.62 times the risk for autism compared to the lowest third of children.

In summary, fetal exposure to acetaminophen was associated with significantly increased risk of childhood ADHD and autism spectrum disorder. Their takeaway is that in utero exposure to acetaminophen is associated with increased risk of ADHD and autism in kids.

Their findings indicate that fetal exposure to acetaminophen is associated with a significantly increased risk of childhood autism in a “dose-response fashion.” This association of autism and Tylenol continued to hold during their sensitivity and subgroup analyses “across strata of potential confounders, including maternal indication, substance use, preterm birth, and child age and sex.”

This is a significant research paper and possibly the most powerful evidence about autism and Tylenol because its study design is quasi-experimental. A quasi-experimental study design is the next most powerful research design after an experimental or randomized controlled trial research design. Practically speaking for this topic, this is effectively the most powerful study design, because, for ethical reasons, scientists cannot conduct an experiment with pregnant mothers and randomly assign them different doses of acetaminophen. Instead, by using previously collected umbilical cord blood, researchers were able to compare naturally occurring acetaminophen dosage effects on ADHD and autism diagnoses without having to conduct such an experiment themselves. They could not control the acetaminophen doses ahead of time as they would in an experiment, but given an existing historical record of acetaminophen dosages, they could determine acetaminophen dosage effects on ADHD and autism diagnoses.

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This randomized control trial, the gold standard for research studies, found that after only 3 months of using Floortime at home, these preschool kids with autism (ASD), showed significant improvement in every area measured by the study!

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In their chapter “Early Intervention of Autism: A Case for the Floortime Approach,” child development scholars Rubina Lal and Rakhee Chhabria conclude with the following:

Early intervention is very important for enhancing the development of infants and toddlers with disabilities, and they are especially crucial in determining the future language, social and behavioral outcomes of very young children with ASD [Autism Spectrum Disorders]. A primary consideration of programs for young children with ASD is to provide an environment that is designed to prevent problem behaviors, promote engagement and participation, and facilitate successful interactions with typically developing peers. Getting the child to engage with materials and activities may prevent challenging behavior occurrence and promote appropriate social behavior. Results of this research support the above findings. Floor time principles state that development begins with a shared world between the caregiver and the young child. The goal is to help the child with ASD emerge from its own world and enter this shared world in order to develop his or her functional and emotional capacities. Floortime achieves this by encouraging child to engage in age and level appropriate play activities with adults and later with peers. The outcomes indicate the effectiveness of Floor time as a method for early intervention of children with autism. The findings of the study may be useful for families who are in need of evidence based and suitable early intervention for children with ASD.

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Introduction

All people have a right to education, including people with disabilities. Some children with autism spectrum disorders (ASD) have significant challenges in their educational path, including additional cognitive delays and physical limitations. A study was conducted on two children, one male and one female, with significant physical limitations and cognitive delay, to see if the Greenspan Floortime Approach helped them achieve the physical education goal of side-rolling. For some children with autism, a traditional classroom environment with teacher-centered learning is not effective because it does not teach the children learning strategies for their particular situation. An educational approach needs to teach students how to learn, think, and motivate themselves so that they can understand complex material and accomplish physical tasks.

The Greenspan Floortime Approach

The field of adaptive education can provide appropriate learning strategies to help students with ASD improve their educational outcomes. The learning strategy used in a 2021 study by Phytanza et al called “Floortime Approach: Can it improve the learning outcomes of side-rolling exercises for Autism Spectrum Disorder Students?” was the Greenspan Floortime Approach. Greenspan Floortime Approach is an interactive methodology that leverages the child’s family and therapeutic relationships to help children through the stages of emotional development. In this approach, the child initiates interaction and parents and other adults follow the child’s interests while spending time with them on the floor.

Research Method

This Phytanza study followed two children, one nine-year-old boy and one eleven-year-old girl. Both children had low learning outcomes, especially in the ability to roll sideways in their adaptive physical education setting. Neither child was able to sit. Researchers taught the participants’ family members the Greenspan Floortime Approach, utilizing the following points:
• Find a time when you are sure you will be uninterrupted for 20-30 minutes with the child. Ideally, find time for 8-10 of these sessions per day.
• Try to stay relaxed and patient. If you become rushed or impatient, the child will become unsettled.
• Empathize with the child’s emotional tone and show it to them, so that they feel understood.
• Be careful with your own feelings, as negative emotions may affect the interactions.
• Monitor your tone of voice and gestures, keeping them joyful, playful, and supportive so the child will want to play with you.
• Follow your child and develop interactions for as long as you are able. All the child’s behavior is meaningful and is an opportunity to develop two-way communication.
• Interact at the emotional developmental level the child is at but encourage them to enter the next stage of development, using a range that is responsive to the circumstances, actions, and reactions of the child.
• Whatever the child wants to do should be allowed as far as it exists within the basic rules of not hitting, damaging anything, or hurting anyone. If the child becomes aggressive because they are overwhelmed, calm them down with a firm but calm attitude.
The tests done for this study involved teaching side-rolling and testing learning outcomes, observing student participation and teacher performance, and documenting the learning process. The task was evaluated by two experts in teaching gymnastics to children with disabilities. The children were tested before and after the use of the Greenspan Floortime Approach.

Results

The students’ abilities to complete the side-rolling test were measured before they started the adaptive learning with the Greenspan Floortime Approach and then again after the intervention. Both children improved their ability to side roll, with the second cycle of evaluation demonstrating that both had attained mastery of the technique.
Accomplishing side-rolling helps students gain confidence, since they can move themselves into a new place. In that way it can reduce feelings of frustration, thereby lowering aggression. Greenspan Floortime Approach helps adults enter the child’s world, following their direction and appreciating them as an individual. It encourages personal attention and familiarity, encourages expression, feelings, and ideas. Greenspan Floortime Approach helps children who have academic problems and behavioral disorders, like emotional control issues, anxiety and depression, and a diverse array of autism spectrum disorders.

Conclusion

Greenspan Floortime Approach helps to improve the learning process in children. In this study, use of Greenspan Floortime Approach in an adaptive physical education task helped children to master the skill of side-rolling. Using this therapeutic approach not only helped the children learn a new skill but it decreased aggression and frustration. The Greenspan Floortime Approach can be used to improve learning outcomes in ASD students needing adaptive physical education.

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In her book review of Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think, Dr. Karen Zelan says the following:

The authors devote several chapters explaining to parents how the Floortime model works. Much of what the authors describe represents informed, effective play psychotherapy. What’s more, the model was devised so that parents could apply its principles in the home. Parents should follow their children’s lead and learn to share their interests with the aim of expanding their psychological and behavioral repertoires. Parents and professionals can best reach the child by letting the interaction evolve gradually, with the child an active participant, sometimes leading the way, sometimes following an inventive adult who varies their joint activities. Emotional engagement is at the heart of the method whereby children come not only to value human interaction but to actually take pleasure in it.

Dr. Greenspan fortunately do not subscribe to the notion that ASD youngsters are incapable of pretend play. In building up a child’s use of words, concepts, and symbols, they stress the importance of pretend play in engaging the emotions. They also recommend “interactive drama” as a therapeutic tool. Citing the multi-modal appeal of attempts to help children think abstractly, the authors assert, “Teach not just with words but also with images, actions, and drama” (p. 124). A three-year-old boy with whom I worked experienced an emotional breakthrough as he dismissed his “bad boys” drama, a story that never ended happily, to join his mother in enacting what police officers actually do to protect families with little kids (Zelan, 2006).

“Once children, with or without ASD, learn the fun of interacting with another human being,” enthuses Dr. Greenspan, “it feels so glorious and natural to them that they begin seeking it out more and more” (p. 77). And it’s never too late, write the authors, to achieve an authentic emotional engagement with even an older autistic youth. I once worked with a fourteen-year-old autistic girl who learned to re-engage emotionally by hugging me, then by jumping into my arms to be carried about. A caretaker’s pleasure in renewed contact with an autistic child doubtless fosters future emotional engagement between them; I was overjoyed that the girl who had grimly avoided personal contact now could not get enough of it (Zelan, 2003).

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The core symptoms of autistic spectrum disorder are all addressed by Dr. Stanley Greenspan’s Floortime Approach. The three components of Dr. Greenspan’s Floortime Approach–a capacity for intimacy, an ability to communicate expressively, and the capacity for meaningful speech–address these missing or underdeveloped abilities of children with autism.

Each of these three missing or underdeveloped functional capacities in children on the autism spectrum require emotional engagement with other people. Going around this emotional engagement requirement, as Applied Behavior Analysis does to train basic and essential skills, does not support the development of the child with autism’s capacity for emotional engagement with other people, especially their parents or caregivers.

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Often, sensory sensitivities in children with autism cause very young children to protect themselves from what they, because of their heightened sensory sensitivity, perceive as excessive stimulation. This is especially true when that perceived excessive stimulation comes from other people, even if those other people are the autistic child’s parents or caregivers.

Maybe the child on the autism spectrum turns away from touch, sound, bold colors or patterns, strong smells or tastes. Maybe it’s only interpersonal intimacy that the child turns away from. On page 14 of Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think, Dr. Greenspan writes that “studies are showing that many children with autism can be very emotional but become so overwhelmed by their feelings that they avoid contact.”

Children on the autism spectrum with sensory sensitivities close off their potential ability for expressive action and meaningful language as they deal with this perceived onslaught of the sensory environment around them and the chaos of their inner world. But, and this should give hope to parents of children with autism, they can and have been persuaded to join their parents’ people world when they feel understood and protected.

Children with autism have sensory sensitivities. Dr. Stanley Greenspan’s Floortime Approach can help.

Parents, please remember that your child’s autism diagnosis is dynamic not static! There is hope!

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How can a parent learn from autism therapy research to help their child? It can be daunting. This is especially true for psychological research on autism therapy. We have already written a parent-friendly guide for helping make sense of research on applied behavior analysis (ABA) therapies for kids with autism.

Here we have translated this research paper from the University of Ottawa in Canada by two Occupational Therapists into parent-friendly language to help parents better understand the key differences between autism therapeutic approaches. We hope parents benefit from a better understanding of this important autism therapy research on Floortime.

Autism Therapy Research Study Shows Positive Results from Greenspan Floortime Interventions for Children with Autism Spectrum Disorders

Children and toddlers with autism often face significant challenges in their social relationships at school and at home. Depending on the severity of their condition, they may have trouble communicating, making friends, or enjoying close family bonds. Different kinds of therapies are available to children who are diagnosed with autism that can help families improve their child’s social ability.

One study looked at a comparison in outcomes for children with autism between different therapeutic approaches: Greenspan Floortime and Applied Behavioral Analysis (ABA). ABA is a well-known, reputable approach where therapists typically break down behaviors into small steps that can be reinforced or rewarded. These small steps can then be combined into greater functional abilities for the child. A criticism of the ABA approach, however, is that the behavioral improvement may not take place in the real-world environment of school or home where the child needs it most. By contrast, Floortime provides intervention techniques that can be used during the child’s ordinary day by parents, caregivers, or therapists, so that the outcomes are more likely to “stick” in the real world. Also, because each child with autism has a developmental schedule that is unique, therapies work best when they can be tailored to the specific child and where they are in their own development.

This study followed one family as they used Greenspan Floortime with their child. The type of study done was called a “single-subject study,” because instead of following a cohort or a group of individuals, it follows one particular individual very closely. The measurement used as an indicator for improvement in the child was the “circles of communication” described by Dr. Stanley Greenspan, where communication is both initiated and the closed by the subject and someone else (usually a parent or caregiver, or a therapist working with the child). The number and complexity of these circles of communication was measured before, during, and after the study. This child showed a statistically significant difference in circles of communication between phases of the study, indicating that the Greenspan Floortime method is an effective therapy for children with autism.

What is the Greenspan Floortime Approach?

The Greenspan Floortime approach is an intervention technique that works at moving a child with special needs through developmental milestones by following the child’s lead during play and building on what the child does to encourage more and more effective interactions. These interactions are called “circles of communication” because they are initiated, or opened, and then go back and forth between participants until they are closed or finished.

During Floortime, the parent or caregiver goes “down on the floor” and plays with their child for 20- to 30-minute periods, encouraging him or her to interact by opening and closing as many circles of communication as possible. This intervention method is particularly interesting to occupational therapists because it takes place in the child’s own real-world environment. This eliminates the gap sometimes seen in behavioral approaches that reinforce behaviors in therapy but not in the child’s own home or school environment. Greenspan Floortime also views each child as a unique individual and approaches their situation holistically, focusing on the child’s relationships and their internal mental state. Behaviors are reinforced within a relationship instead of externally through a reward-based system.

Single-Subject Study: Who was the subject?

In this study, the subject was a boy aged three and a half years old who had been diagnosed with autism at the age of two and a half. He was recruited through an advertisement for the study that was published by the Autism Society. He had not had any previous intensive treatment, and he did not have any other conditions that would affect the study. Informed consent was obtained from his mother, and the ethics board at a local university oversaw the ethics of the study.

The boy in this study had achieved physical milestones such as crawling and walking, feeding, and toilet training within the normal time frame, but his language and play skills were delayed. He was nonverbal and only used a few spoken words to communicate. He used a picture exchange communication system (PECS) to make choices at snack time or meals. He was enrolled in a community daycare and had the support of occupational therapists and speech and language pathologists through the school. To express his needs, he was able to take an adult by the hand and indicate what he wanted, but little interaction took place during his play, and he couldn’t use toys very well.

The study began by measuring his functioning using some standardized tests like The Childhood Autism Rating Scale (CARS), which differentiates children with autism from children with other developmental delays. The test was administered by the child’s occupational therapist. Another test was The Sensory Profile, a standardized questionnaire for children aged three to 11 that looks at the child’s ability to process sensory information. A third assessment was the Functional Emotional Assessment Scale (FEAS), which attempts to determine the child’s emotional capacities in the context of family relationships. The boy and his mother were also observed with respect to Dr. Greenspan’s six developmental milestones of emotional functioning. This pre-intervention information was important because it was used to show any changes related to using the Greenspan Floortime interventions.

For this study, circles of communication were used as one variable that could be measured. They can be observed and counted, can be summarized and collected throughout the study, and can be used to show progress according to the frameworks. All the sessions in the study were videotaped and then the circles of communication were determined from viewing the videos. During the intervention phase of the study the boy’s mother was also asked to keep a journal to record his progress at home.

The child was seen four times a week for 45-minute sessions at a private clinic. During these sessions, the boy’s mother participated with him. The first 30 minutes of each session were used for observation during the first phase, and intervention during the second phase of the study. The last 15 minutes of each session involved discussion with the boy’s mother, either by gathering data from her or by coaching her in the Greenspan Floortime intervention techniques.

Observation

Each time the boy was observed he was given age-appropriate toys and materials like baby dolls, toy cars and a garage, and stuffed animals. The materials were intended to provide sensory, cause-and-effect, and symbolic play opportunities.

Intervention

The second phase of the study was the intervention stage, which took place over 28 sessions or seven weeks. The intervention stage was three times the length of the observation stage, which helped the researchers see whether changes were actually occurring and were not just natural variations in behavior. During the intervention session the Greenspan Floortime techniques were taught to the boy’s mother. The therapist taught the mother different things like intentionally giving the child a different toy than he requested (what they called being “intentionally obstructive” but which most parents would call “friendly teasing”), engaging in pretend play like pretending to be asleep, and by using verbal suggestions while she played with her child. The mother was encouraged to practice different strategies to keep her son engaged, and to watch him carefully for signs that he was losing interest or that he was getting overwhelmed.

Researchers took the recorded videos of the sessions and collected data from them, putting the information into graphs and other data visualizations. Statistical analysis was performed on the data from the study. The results of the study confirmed that the boy being study had mild to moderate autism based on his standardized tests. He was essentially nonverbal and used toys inappropriately (meaning he would often throw the toys or focus very closely on some insignificant part of the toy). He frequently engaged in running or spinning that disrupted his ability to participate in daily routines. He was easily distractible when there was a lot of sensory stimulation in the environment. He liked touching people or objects but did not like the kind of touching involved in grooming activities. He was delayed in his developmental emotional milestones. His mother, on the other hand, received a “normal” score for her ability to interact with her son in a calm and sensitive manner. She tended however to use language that was too complex and to talk too much during interactions, which was getting in the way of keeping her child engaged.

The Mother’s Journal

Over the course of the study the mother kept a journal documenting the sessions she held each day—an average of three per day. She held shorter sessions on weekdays and usually they were associated with his daily routine, like taking a bath or having a meal. On weekends, she had longer sessions, up to 45 minutes, where there were more games and more circles of communication. The journal showed progress in the child’s abilities to increase the complexity of games they played and in playing them with other people in the family. The mother also noted in her journal that her son started initiating interactions with her by seeking her out or inventing new games. He still did not do very much pretend play, but his use of toys became more appropriate, like feeding a doll with a bottle, for example.

The mother also shared her personal impressions of her child’s progress in her journal. Communication between her and her child became more spontaneous, and the circles of communication became more rapid even when they were nonverbal. She was thrilled that her child was able to take part in childhood activities without becoming distressed. She noted that after the interventions, her son was able to listen to his father read a bedtime story and point out the pictures, whereas before he would rip the book out of their hands. These activities became a source of shared pleasure that they wanted to repeat. “It warms the heart,” she wrote, “to see my child with glee in his eye.”

The Effectiveness of Greenspan Floortime for Autism

The purpose of this study of one child and his family was to determine if Greenspan Floortime was an effective intervention for a child diagnosed with autism. There was a lot of variability in the data that was collected because the circles of communication being measured were often very different both in length (10 minutes versus 45 minutes) and in the increasing complexity of the interactions. Despite the variations in the data collected, however, there was a significant different in the number of interactions in the observation phase of the study compared with the intervention phase of the study. This study showed encouraging evidence that Greenspan Floortime benefits children with autism who use it as an intervention. More studies on larger groups of children and their parents would be useful as well.

Conclusion

Children diagnosed with autism benefit from early, intensive intervention programs. The Greenspan Floortime method is an intervention approach that is becoming popular and is being used by an increasing number of clinicians and parents. Few studies have been completed on this approach despite its popularity. This single-subject study was done to provide more insight on the effectiveness of the Greenspan Floortime approach and justify additional research into the use of this intervention with children who have autism spectrum disorders. This study showed that the Greenspan Floortime approach resulted in a significant increase in the numbers of interactions in the intervention phase of the study compared with the initial observation phase of the study. The mother’s journal was also helpful, because it provided a parent’s perspective on the use of Greenspan Floortime in the home. Because of the encouraging results of this preliminary study, more research on this intervention approach is called for.

More Information on Autism Therapy Research

We have a number of resources available to help parents and even professionals make sense of the growing body of autism therapy research on Greenspan Floortime. These research findings can be found within our Autism category, and, of course, to learn more about Floortime and how it helps all children, please consider one of our many courses. If you have an autism therapy research suggestion for our team, please let us know!

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