Similarities and Differences Between ESDM and DIR


The similarities are that they (1) Both see autism as a neurobiological disorder whose course can be significantly affected by the early caregiving environment; (2) Both work with very young children, often 2-years old or even younger; (3) They both organize their models around a linear developmental framework that refers to “normal development”, in other words – at this age the typical child should have this competency, and then at this other age, he should be able to do this; (3) They both include the parents – but to varying degrees; (5) They both have a prescribed set of techniques that the therapist has to master; (6) They both use videotape as a teaching tool; (6) They both track progress through the accomplishment of specific developmental competencies that are set forth in their writings (such as the achievement of language goals or goals in pretend play).

The differences are that (1) ESDM derives from ABA (the behavioral method that Lovaas introduced in the 60’s), though not DTT (discrete trial training), while DIR derived from observations that the young children in a disadvantaged population had a high incidence of developmental disorders; (2) The ESDM is a manualized treatment that involves the clinician to chart goals and results for each session, and the DIR – while requiring adherence to specific techniques – does not require a specific number of particular responses from the child within a  time frame; (3) ESDM has impressive empirical evidence to demonstrate its effectiveness including a very large n (660) and following the children from 6 months to 36 months; DIR is only just now starting to do efficacy studies (there are some long term follow up studies but only one empirical study that I know of, following children 12 months; (4) ESDM really emphasizes starting at age 2 and though DIR also likes to start early, it often doesn’t  start that young; (5) ESDM likes to maintain the “coherence” of the intervention by NOT involving other disciplines like OT and speech, believing that this intervention is comprehensive enough in itself, whereas DIR from the beginning has worked with an interdisciplinary team; (6) ESDM emphasizes language acquisition as perhaps its critical first goal, whereas DIR emphasizes the establishment of joint attention first, believing that language acquisition will follow; (7) DIR emphasizes visual spatial orientation more than ESDM, believing that this is frequently disturbed in ASD children and interferes with social engagement; (8) The DIR technique emphasizes using affect and the relationship (joint attention) more than ESDM; (9) DIR almost always works by coaching the parents and not the therapist working directly with the child, whereas, ESDM often has the parent in the room but has the therapist working directly with the child and the parent watching – then they have separate sessions to teach the parents.

Evidence that DIR and ESDM are learning from each other or at least coming closer together is as follows: (1) Sally Rogers talked about the importance of the ESDM initiative to train parents; this is similar to the original technique of DIR of coaching parents. (2) Although Sally Rogers emphasized the coherence of the treatment and how other disciplines were not involved in order to accomplish this coherence, some of her slides included involving OT and speech specialists, so I imagine they are included if only as consultants or advisors. (3) Serena Wieder talked about the effort to obtain validation in empirical research for DIR. (4) The DIR intervention is presented as designed to suit the individual child – in this way distinguishing it from ESDM, yet the intervention model follows a prescribed path that takes the child and parent from one level to the next in a linear progression. (5) Although Dr. Wieder also presented DIR as attending to the inner world of the child, she did not show us examples of this in her films. (6) In addition, the DIR training does not seem to produce clinicians – excellent though they tend to be – who are familiar with this particular domain child psychotherapy; that is, DIR clinicians generally are skilled at working with parent and child at the lower “levels” of development as defined by the DIR model, but not so much at the higher level of symbolic function.

Read this blog in Spanish. 

Photograph by Ginger Gregory 

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