MHGCJ – 2020

Mental Health: Global Challenges Journal

ISSN 2612-2138

Implementation of the DIR Model and the

DIR/Floortime Approach in the System of Palliative

Care for Children

Elena Akulova

Expert & Training Leader, Interdisciplinary Council on Development and Learning (ICDL), Minsk, Belarus

Abstract

Introduction. One of the systems that can be used in the system of palliative care for children is

the Developmental Individual Relationship (DIR)/Floortime concept, which can be flexibly

adapted to individual features of a child, and at the same time it has intelligible and clearly-

defined tools for work and interaction, that take into consideration not only individual peculiarities

of a patient, but also their parents and specialists.
Purpose. The purpose of the paper was to review the possibilities and prospects of using

DIR/Floortime model in the system of palliative care for children.
Methodology. The paper was prepared on the basis of input from Belarusian Children's Hospice

and also took into account experience of implementation of the DIR/Floortime Model (report

information of ICDL’ specialists).
Results and Discussion. In the course of the work the main tasks for providing palliative care to

sick children were outlined and 6 points of introduction of the DIR /Floortime concept into this

system were singled out.
Conclusions. The main postulates of the DIR concept fully coincide with the modern principles of

palliative support. Using DIR/Floortime Model also can solve urgent tasks of the system of palliative

care for children: build a team-based, positive, supportive and safe relationship around a child

and family; help to prevent conflicts; improve the emotional background of the child in care.

Keywords

Child psychology, mental health, education, palliative care, DIR Model, DIR/Floortime Approach.

Address for correspondence:

Elena Akulova, Expert & Training Leader, Interdisciplinary Council on Development and
Learning (ICDL), Minsk, Belarus e-mail:

akulova.al@gmail.com

This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Akulova, 2020

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI:

https://doi.org/10.32437/mhgcj.v3i1.75

Submitted for publication:

March 2020

Received for publication:

March 2020

Accepted for publication:

June 2020

Introduction

Palliative care for sick children involves

providing assistance to a wide category of

patients that includes  not only oncology patients
but also children with congenital or/and acquired
diseases  and  (multiple)  complex  developmental
disorders.  Thus,  we  cannot  talk  about  a  narrow

MHGCJ – 2020

Mental Health: Global Challenges Journal

https://mhgcj.org

ISSN 2612-2138

range  of  diagnoses:  every  child  has  his  own
individual  aspect  of  a  disease.  A  team  of
specialists, who provide palliative care for a family
and a child, are tasked not only with medical, but
also psychological and pedagogical support of a
child  and  his  parents.  One  of  the  standards  of
high-level  palliative  care  is  to  provide  assistance
not singularly to a child, but to the entire family of
a patient. In addition, the extensive experience of
palliative support of patients in different countries
shows  that  the  emotional  background  of  a
palliative  patient  has  a  direct  impact  on  the
somatic  and  mental  condition  of  the  child  and
even on the nature of the course of his\her disease
(Itskovich, G.,2018; 2019).

The system of palliative care in many countries

is  currently  being  created  and  established  or
improved.  The  model  of  care  for  terminally-ill
children  undergoes  changes  for  humanism  and
personalized approach, which takes into account
not only a patient’s interests, but also peculiarities
of  their  stay  in  the  family.  However,  even  in  a
personalized system of care specialists of different
profiles  who  work  in  a  team  need  a  common
frame of orienting points. It will make the teamwork
focused,

well-coordinated

and

consistent

(Gomozova, E. S., & Gomozova, M. A., 2019). One
of the systems that can be used in the system of
palliative  care  for  children  is  the  Developmental
Individual  Relationship  (DIR)/Floortime  concept,
which  can  be  flexibly  adapted  to  individual
features  of  a  child,  and  at  the  same  time  it  has
intelligible  and  clearly-defined  tools  for  work  and
interaction,  that  take  into  consideration  not  only
individual  peculiarities  of  a  patient,  but  also  their
parents

and

specialists

(Pajareya,

K.,

Sutchritpongsa,  S.,  Kongkasuwan,  R.,  2019;
Boshoff, K., Bowen, H., Paton, H. et all., 2020; Hess,
E.,  2020).Although  Canada  and  Ukraine  have
vastly  different  histories,  both  countries  include
populations  who  have  experienced  trauma  and
oppression  and  are  far  from  achieving  positive
peace. We have attempted to illustrate that, while
the details are different, people in both countries
have  experienced  and  continue  to  experience
the  impact  of  colonization  and  other  related
structural, cultural and direct violence

. In addition

to  people  suffering  with  more  traditionally
acknowledged  mental  illnesses  such  as
schizophrenia  and  bipolar  disorder,  there  is  slow
movement not only towards understanding whole

health  of  individuals  and  communities  as
described by the World Health Organization (2005)
but  also  towards  institutionalizing  systems  and
cultures  of  care  that  can  support  ongoing
empowerment  of  individuals  and  communities
that facilitate peaceful development.

Purpose

The purpose of the paper was to review the

possibilities and prospects of using DIR/Floortime
Model in the system of palliative care for children

Methodology

The paper was prepared on the basis of input

from  Belarusian Children's  Hospice  and  also  took
into account experience of implementation of the
DIR/Floortime  Model  (report  information  of
Interdisciplinary  Council  on  Development  and
Learning’ specialists).

Results and Discussion

Therefore, providing of palliative care for sick

children has the following tasks:

- To organize effective teamwork of specialists

of different profiles within a single framework of the
palliative  system  for  a  particular  client;  it  implies
using  single  terminology  and  following  the
common assistance concept, which experts can
rely  on  for  their  work  to  be  consistent  and
coordinated.

- A child's family must be included into the

system of assistance: family members need to be
trained specific methods of care and medical
manipulations, but also it is crucial to teach them
the correct interaction with the child and to
provide them with psychological counselling and
spiritual support if necessary.

- Children with complex diseases are often

subjected  to  chronic  stress  associated  with
frequent  hospitalizations,  surgical  treatment,  as
well  as  stress  caused  by  instrumental  and/or
psychological trauma. These problems also need
to be systematically addressed.

- Professionals who work in the field of palliative

care often face intense severe experiences, which
puts them at risk of emotional burnout. In this
regard, it is necessary to focus on burnout

MHGCJ – 2020

Mental Health: Global Challenges Journal

https://mhgcj.org

ISSN 2612-2138

prevention and psychological well-being of
specialists.

Implementation of the DIR/Floortime concept

into the system:

1) The DIR concept is both multidimensional

and  flexible.  The  first  aspect  of  the  DIR  is  the
development  component  which  shows  us  the
current  state  of  the  child  and  his  actual  level  of
development.

Personalized

approach

presupposes that we take into account not only a
child’s  level  of  development,  but  also  all  his/her
individual  characteristics:  history  of  illness,  his
sensory-motor  profile,  specifics  of  the  family
system  where  the  child  resides  (resources  and
"weak"  areas,  history  of  the  disease  as  seen  by
family  members,  psychological  state  of  close
relatives of the child, etc.). Component "D" shows
us how to build interaction with each specific child
and their family based on the previous two points.
Besides,  there  are  several  other  "dimensions"  –
these  are  the  characteristics  of  each  involved
specialist, their individual profile, experience, skills
and  current  emotional  state.  Basing  on  this  data
we  can  personalize  interaction  of  all  specialists
with a patient and/or their family and fully adapt it
to the child's needs.

2) The crucial role of affect in the

DIR/Floortime model needs to be emphasized. The
DIR/Floortime teaches us to establish and develop
emotionally  healthy  and  positive  relationships.
Besides,  special  attention  is  paid  to  compliance
with  ethical  principles,  as  well  as  to  respect  for
each  patient,  their  family  members,  and
specialists  involved.  The  DIR/Floortime  gives  us
specific  tools  for  building  emotionally  warm
relationships, with a full range of acceptance of all
emotions  experienced  by  all  participants  of  the
process.  Such  practice  and  attitude  has  a
therapeutic  role  in  itself  –  it  helps  to  prevent
emotional burnout of everyone involved and helps
to  regulate  the  emotional  background  of  a
patient,  which,  as  we  have  already  indicated,
directly affects his/her condition as a whole.

3) Reflection. The DIR/Floortime concept

increases the level of awareness in the specialist-
child or specialist-parent interaction. It implies self-
improvement of each specialist, development of
their self-awareness, which leads to the more

conscious and careful usage of their skills and
abilities in work.

4) Team. The DIR / Floortime suggests

teamwork of different specialists – of medical,
psychological

and

pedagogical

profiles,

rehabilitation  specialists,  etc.  However,  these
specialists,  provided  they  have  the  necessary
training,  have  an  opportunity  to  coordinate  their
work according to the common DIR parameters,
and form a single joint vision of the dynamics and
prospects of a child in their care.

5) Family. The DIR/Floortime concept

emphasizes a huge role of the family system and
of cooperation with family members – those who
take  care  of  the  child.  They  become  the  main
"players" in the team. The advantages of such an
approach  are  undeniable:  it  allows  parents  to
cope with the trauma of the disease, they feel the
support  from  outside  and  realize  their  important
role within the team, also it facilitates the work of
specialists,  since  some  part  of  the  work  can  be
taken over by trained parents.

6) Child. For many years in post-soviet

countries  the  role  of  a  seriously  ill  patient  was
"inanimate"  and  impersonal.  These  people  were
treated  as  objects  that  needed  to  be
manipulated  and  cared  for.  Only  recently  they
have raised a question of the quality of life of such
people  and  humane  attitude  to  them.  The
DIR/Floortime  approach  helps  us  to  avoid
excessive  stress  while  dealing  with  seriously  ill
children. As practice shows, the atmosphere of the
medical  institution  changes  dramatically  for  the
better  and  stress  levels  of  patients  and  their
relatives  reduce  significantly  when  the  staff  know
and  successfully  use  the  tools  to  establish
emotionally  warm  and  safe  relationships.
Moreover,  it  increases  work  motivation  and
improves the emotional state of employees of the
institution.

Limitations of the study

Potential challenges in the implementation of

the DIR/Floortime approach in the system of
palliative care

1) The first difficulty we might encounter is the

delay of important results. It is not enough just to
train the staff and give them "tools" of the
approach to get some persistent changes in the

MHGCJ – 2020

Mental Health: Global Challenges Journal

https://mhgcj.org

ISSN 2612-2138

work of the team. Each team member will have to
go through a stage of internal changes, and work
on self-reflection, empathy, increasing awareness
of their experiences and interactions, both in the
team and with patients. However, in the long run,
this very approach helps to get a better result in
terms of team cohesion, improving motivation
and emotional state of employees.

2) The use of the DIR/Floortime requires a very

subtle  adjustment  of  the  connection  specialist-
child,  and  there  might  appear  situations  when  a
child  and  a  specialist  will  not  coincide  in  some
parameters  (individual  characteristics,  emotional
state, etc.). This will require "replacing the player" or
taking some other action to deal with the problem.

3) In very rare cases, some team members

might  consider  the  DIR/Floortime  concept
unsuitable  due  to  their  personal  characteristics.
They  might  find  it  difficult  to  use  non-directive
methods,  as  well  as  to  work  with  their  emotions.
Each such  case requires an individual approach
and search for solutions.

4) Staff training will take a certain amount of

time, and then, after training, regular supervisions
need  to  be  provided.  Professionals  who  provide
assistance  have  to  complete  not  only  the
introductory 101 course, but also 201 and/or 202
DIR/Floortime  courses.  Parents  and  attending
personnel  (nurses,  junior  nurses)  can  complete
only the introductory 101 DIR/Floortime course, but
they  need  to  receive  the  support  of  a  more
qualified specialist on a regular basis.

5) The work of such a team requires regular

supervisions by an independent external expert of
the appropriate qualification for high efficiency
maintenance.

Conclusions

Due to its flexibility, adaptability, and inclusion

of the emotional aspect, the DIR/Floortime model
can be widely and successfully used in the system
of palliative care. The main postulates of the DIR
concept fully coincide with the modern principles
of  palliative  support.  In  addition,  the  use  of  this
model  not  only  increases  the  competence  of
employees,  but  also  solves  other  tasks:  team
cohesion,  prevention  of  emotional  burnout,
development

emotional

intelligence,

awareness and empathy of everyone involved.
Building a team-based, positive, supportive and

safe relationship around a child and family helps
to prevent conflicts, and to improve the emotional
background of the child in care.

Acknowledgments

Thanks to my supervisor Galina Itskovich, LCSW-

R,  DIRFloortime  Expert;  Special  thanks  to  Anna
Garchakova,  Director  of  the  Belarusian Children's
Hospice  end  staff  of  the  Belarusian  Children's
Hospice.

Conflict of interest

Author declares no conflict of interests.

References

Boshoff, K., Bowen, H., Paton, H., Cameron-Smith,

S., Graetz, S., Young, A., & Lane, K. (2020). Child
Development  Outcomes  of  DIR/Floortime  TM-
based  Programs:  A  Systematic  Review.
Canadian  Journal  of  Occupational  Therapy,
87(2), 153-164.

Gomozova, E. S., & Gomozova, M. A. (2019). The

DIRFloortime Approach in Speech Therapy for
Speech Development in Children with ADs and
Other Disorders. Recommendations for Parents
and Teachers. Autism and Developmental
Disorders, 17(2), 46-57.

Hess, E. (2020). DIR®/Floortime™. Infant Play

Therapy: Foundations, Models, Programs, and
Practice.

Itskovich, G. (2018). Infant and Parent Mental

Health:  developmental  trajectory  as  a
communal concern: Developmental trajectory
as  a  communal  concern.  Mental  Health:
Global  Challenges  Journal,  1(1),  29-31.
https://doi.org/10.32437/mhgcj.v1i1.14

Itskovich, G. (2019). DIR®-informed approach to

anxiety and trauma in school age children.
Mental Health: Global Challenges Journal,
2(2),

11-25.

https://doi.org/10.32437/mhgcj.v2i2.56

Itskovich, G. (2019). On Affective States and the

Use of Affect in DIR Floortime Clinical Practice.
Autism and Developmental Disorders, 17(2), 5-
17.

Pajareya, K., Sutchritpongsa, S., & Kongkasuwan,

R. (2019). DIR/Floortime® Parent Training
Intervention for Children with Developmental