Articles & Press

Research Evidence Re: Developmental-Relationship Based Interventions for Autism
July 2017
Diane Cullinane, M.D., Susan Gurry, Ed.D, Richard Solomon, M.D.

Treatments for children with autism spectrum disorders (ASD) are generally grouped in broad categories of ‘behavioral’ or ‘developmental.’ The Agency for Healthcare Research and Quality (AHRQ)) define behavioral interventions “to include early intensive behavioral and developmental interventions, social skills interventions, play-focused approaches, interventions targeting symptoms commonly associated with ASD and other general psychosocial approaches.” (AHRQ, 2014)…The outcomes…, using valid and reliable measures, document that DRBI consistently improve caregiver sensitivity, responsivity, and effectiveness leading to the improved social relationships and functional development including improvement in joint attention, initiation, language, play skills, social interactions and functional development…While there is agreement that children with ASD present a wide range of unique abilities and challenges, and that no particular treatment approach is effective for all children (National Autism Center, 2015), public policies often limit access to treatment options. It is important that clinicians as well as families are able to make informed decisions based upon knowledge of treatment options and access to all evidence-based treatment modalities. Click here to read the full article


PCDA’s Advocacy Brings Sense of Relief
Pasadena Outlook – February 2015
Written by 

Within moments of entering the Pasadena’s Professional Child Development Associates’ lively and massive Lake Avenue center, expect to experience a bit of sensory overload.

This isn’t the white-walled, quiet headquarters most come to expect from an organization treating children with developmental or behavioral challenges. During a tour of the vibrant 20,000-square-foot facility, you’re likely to simultaneously see parents and pathologists working together, hear an occupational therapist encourage a child with cerebral palsy to take the next step, and catch a whiff of something a nutritionist cooked up in the kitchen to help a child work through eating difficulties rooted in something deeper.

But the children and families served by PCDA sense something more when they step through the doors, a feeling that can’t be seen or touched. The mother of Anthony Rodriguez said the feeling was the certainty of support. Cooper Clough’s parents called it a belief in their son’s future. No matter how the families phrase it, co-founder and Executive Director Dr. Diane Cullinane has heard it all since the organization’s launch in 1996. Read More


Parent’s/Caregiver’s Relationship and the Impact on Nutrition
ICAN October 2013
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PCDA Hosts Harvest Moon Dinner and Auction 
Pasadena Outlook – September 25, 2014

The Question Is
Dr. Diane Cullinane and PCDA Board member Joseph Lee were recently featured on California State Senate candidate Anthony Portanino’s TV show “The Question Is…”. This particular episode was called The Question is Autism.


Evidence Base for the DIRFloortime® Approach 2014 Update (2/2015)
Diane Cullinane, M.D., FAAP (Originally Published Feb 2011)

Due to the recent budget cuts in California, the ‘evidence’ to justify public funding for DIR®/FT programs is currently under scrutiny by regional centers in California. This article attempts to summarize the most current research evidence pertaining to the DIR®/FT approach, which will not only provide sufficient basis for a determination that DIR®/FT is evidence-based but will also present an historical view that shows that the field of intervention for children with PDD is shifting from more behavioral approaches towards more developmental models overall.

From Trailer bill: “Evidence-based practice” means a decision making process which integrates the best available scientifically rigorous research, clinical expertise, and individual’s characteristics. Evidence-based practice is an approach to treatment rather than a specific treatment. Evidence-based practice promotes the collection, interpretation, integration, and continuous evaluation of valid, important, and applicable individual- or family-reported, clinically-observed, and research-supported evidence. The best available evidence, matched to infant or toddler circumstances and preferences, is applied to ensure the quality of clinical judgments and facilitates the most cost-effective care. Click here for the complete article.


What is DIR®/Floortime and Why is it “Best Clinical Practice”?
Diane Cullinane, M.D., FAAP (Published 9-22-09)

The Developmental, Individual Difference, Relationship based approach to helping children with special needs, known as DIR®, was described by Dr. Stanley Greenspan and Serena Wieder beginning in the 1980s.  This approach is the culmination of years of observation and study of infants and children, done by many outstanding researchers since the 1950s.  Dr. Greenspan and Serena Wieder brought together the knowledge from developmental studies, and mental health research, and recognized the critical importance of relationships and affect to learning. DIR®/Floortime is a framework for understanding child development, a philosophy that emphasizes the critical importance of relationships and affect, and a set of treatment strategies built upon those principles.  DIR® is a broad and comprehensive approach which encompasses all disciplines that work with children. Click here for the complete article.


Social Skills Group Training using a Developmental Approach Evidence Based Practice
Diane Cullinane, M.D., FAAP (Published September 2011)

The development of social skills, specifically skills in relating to peers, is an important capacity that provides the foundations for life long success. Challenges in the development of social skills impact individual happiness and family function for many children with developmental disabilities, especially those with autism. Indeed, deficits in social behaviors are a major component of the diagnostic criteria for autism. In a survey done at Tri-counties Regional center, parents of children with autism reported that social skills were their number one concern.  A study of children with ASD in elementary school showed that children with autism were less accepted and had fewer reciprocal friendships than matched peers at each grade level, and that the deficits increased with advancing age.  A detailed review of the theoretical understanding and approaches to social skills intervention is available in the report of The Committee on Educational Interventions for Children with Autism by the National Research Council (NRC). They note: “Interaction with peers is another dimension of children’s social development that becomes increasingly important for children…” Click here for complete article.


Evidence-based Practice and Practice-based Evidence
Diane Cullinane, M.D., FAAP

“Evidence-based” has become the gold standard for determining funding. The terms evidence based medicine, treatment, guidelines, practice, models, etc are often used interchangeably. The distinctions are particularly important for the care of children with disabilities and complex medical conditions. Evidence based treatments refer to specific treatments which have been studied on specific and limited populations. These types of treatments are more amenable to study and validation because they limit variables, such as a single diagnosis, and use more easily measured outcomes. Affect, initiative, creativity, warmth, and reciprocity in complex dynamic systems are less often measured. For children with complex conditions, EBTs must be integrated into EB practice. Sackett1 defined evidence based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Click here for complete article. 

What is the DIR®/FloortimeTM Model?
Stanley Greenspan, M.D. & Serena Wieder, Ph.D.

The Developmental, Individual Difference, Relationship-based (DIR®/FloortimeTM) Model is a framework that helps clinicians, parents and educators conduct a comprehensive assessment and develop an intervention program tailored to the unique challenges and strengths of children with Autism Spectrum Disorders (ASD) and other developmental challenges. The objectives of the DIR®/FloortimeTM Model are to build healthy foundations for social, emotional, and intellectual capacities.

  • The D (Developmental) part of the Model describes the building blocks of this foundation. This includes helping children to develop capacities to attend and remain calm and regulated, engage and relate to others, initiate and respond to all types of communication beginning with emotional and social affect based gestures, engage in shared social problem-solving and intentional behavior involving a continuous flow of  interactions in a row, use ideas to communicate needs and think and play creatively, and build bridges between ideas in logical ways which lead to higher level capacities to think in multicausal, grey area and reflective ways. These developmental capacities are essential for spontaneous and empathic relationships as well as the mastery of academic skills.

Click here for the complete article.


Helping Children Master New Experiences: DIR® Applied to Increasing Flexibility Around Eating
Stanley Greenspan, M.D.

One of the most difficult challenges for parents and therapists is to help children become more flexible eaters. This happens particularly when the children are rigid, stubborn, and narrow in their choices. It is often due to sensory processing differences, where particular tastes and smells may be aversive and lots of controlling behavior has developed to minimize surprises.

The strategy, which is based on the DIR® model, involves harnessing the child’s initiative and problem-solving and, if possible, verbal or symbolic mastery. This is done in the context of pleasurable, regulating experiences and the gradual modulation of sensory overreactivity in areas of taste and smell. The strategy involves first establishing shared attention and engagement with the child through Floortime play and then in eating contexts. A critical step is to reduce any anxiety from a history of power struggles around eating and replace it with calm, regulating experiences. Again, this begins simply with regular Floortime sessions where a child is tuned into at his functional level in terms of his sensory profile, with nurturing and follow the child’s interest-type interactions. As one takes this now soothing, regulating, pleasurable relationship to the eating situation, one is likely to see increased anxieties and negative behaviors. It’s therefore important, once having established pleasurable, soothing interactions in play, to establish this around eating as well. Therefore, begin with foods the child enjoys and tolerates well and don’t try to introduce new foods or stretch the child’s capacities at the outset.

Click here for the complete article.

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