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Home-based DIR/Floortime (TM)

Intervention Program for Preschool
Children with Autism Spectrum
Disorders: Preliminary...
Article in Physical & Occupational Therapy in Pediatrics May 2014
DOI: 10.3109/01942638.2014.918074 Source: PubMed

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Physical & Occupational Therapy in Pediatrics, Early Online:112, 2014


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DOI: 10.3109/01942638.2014.918074

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ARTICLE

Home-based DIR/FloortimeTM Intervention

Program for Preschool Children with Autism
Spectrum Disorders: Preliminary Findings
Shu-Ting Liao1 , Yea-Shwu Hwang1 , Yung-Jung Chen2 , Peichin Lee3 ,
Shin-Jaw Chen4 , & Ling-Yi Lin1
1

Department of Occupational Therapy, College of Medicine, National Cheng Kung

University, Tainan, Taiwan, 2 Department of Pediatrics, College of Medicine, National
Cheng Kung University Hospital, Tainan, Taiwan, 3 School of Occupational Therapy,
Chung Shan Medical University, Taichung, Taiwan, 4 Yins Clinic, Tainan, Taiwan

ABSTRACT. Improving parentchild interaction and play are important outcomes for
children with autism spectrum disorder (ASD). Play is the primary occupation of children. In this pilot study conducted in Taiwan, we investigated the effects of the developmental, individual difference, and relationship-based (DIR)/FloortimeTM home-based
intervention program on social interaction and adaptive functioning of children with
ASD. The participants were 11 children with ASD, ages from 4569 months, and their
mothers. Mothers were instructed the principles of the approach by an occupational
therapist. All 11 children and their mothers completed the 10-week home-based intervention program, undergoing an average of 109.7 hr of intervention. Children made
significant changes in mean scores for emotional functioning, communication, and daily
living skills. Moreover, the mothers perceived positive changes in their parent-child interactions. The findings of this pilot study contribute to knowledge regarding the effects
of home-based DIR/FloortimeTM intervention program on increasing the social interaction and adaptive behaviors of children with ASD in Taiwan.
KEYWORDS:
Adaptive functioning, autism spectrum disorders (ASDs),
DIR/FloortimeTM , emotional functioning, home program, home-based

Autism spectrum disorder (ASD) is a lifelong developmental disability that is characterized by impairments in communication and reciprocal social interaction, and
as well as restricted and repetitive behaviors or interests (American Psychiatric
Association [APA], 2000). The Centers for Disease Control and Prevention in the
United States (2012) have estimated that an average of one in 88 children has ASD.
In addition, reports indicate that the prevalence of ASD is increasing in Western
Address correspondence to: Ling-Yi Lin, Sc.D., Assistant Professor, Department of Occupational Therapy,
College of Medicine, National Cheng Kung University, No. 1 University Road, Tainan City 701, Taiwan
(E-mail: lingyi@mail.ncku.edu.tw).
(Received 25 August 2013; accepted 11 April 2014)

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Liao et al.

countries as well as in Taiwan (Lin et al., 2009). In 2007, the annual rate of increase
in ASD prevalence was 16.5%, the highest among all disabilities (Taiwan Ministry
of the Interior [TMOI], 2008). The number of identified persons with ASD in Taiwan was 12,339 in 2012 (TMOI, 2013). Thus, effective interventions are needed to
improve the function of children with ASD.
The National Research Council (2001) recommended that interventions for children with ASD have the following characteristics: (a) An implementation intensity
of 25 hr per week (intensive duration); (b) a therapist-to-client ratio of 1:1 or 1:2;
(c) early intervention (from 18 months to 6 years of age); and (d) structured and
strategic approaches for improving language, social, and behavioral deficits. Children with ASD and their families, however, may encounter financial and human
resource challenges. When educational and medical resources are limited, interventions with the aforementioned characteristics cannot be feasibly established.
Several researchers (Case-Smith & Arbesman, 2008; McConachie & Diggle 2007;
Schultz et al., 2011) have asserted that caregivers and family members should be involved in therapy programs that incorporate recommendations into daily routines
in order to meet the required intensive duration.
The social impairment of children with ASD is a crucial concern. In the past
two decades, parentchild interaction has attracted increased attention. Numerous
studies (Kim & Mahoney, 2005; Mahoney & Perales, 2003, 2005) have confirmed
the importance of parent-child interaction, as well as the value of intervention programs that support parentchild relationships. Parentchild interaction is strongly
linked to childrens social abilities (Crouter & McHale, 2005). A qualitative study
showed that high-quality parentchild relationships can enable caregivers to build
a connection with children (Charles & Berman, 2009). Smith et al. (2008) reported
that the use of specific caregiving strategies can moderate the depressive symptom
of caregivers. Furthermore, occupational therapists assert that, because play is the
primary occupation of children, it provides a natural means for children with ASD
to develop social skills (Morrison & Metzger, 2001).
The social-pragmatic developmental approach has been recommended for children with ASD (Prizant & Wetherby, 1998). This approach is based on the developmental, individual-difference, relationship-based (DIR)/FloortimeTM model
(Greenspan & Wieder, 1997), which was designed to improve childrens language,
cognition, emotional, and social skills through meaningful interactive relationships.
Family involvement is a crucial aspect of the DIR/FloortimeTM model. In addition,
this model emphasizes the notion that real learning occurs not in artificial contexts,
but in real contexts, and generalizes acquired skills into various types of social interaction. The DIR/FloortimeTM model comprises six developmental milestones of
emotional functioning that allow professionals to assess childrens intellectual and
emotional maturity. The critical element of these six developmental milestones is
reciprocal communication between the child and the caregiver (Greenspan et al.,
2001).
The DIR/FloortimeTM model is gaining popularity in Taiwan since parents make
great efforts to find a cure for their childs ASD (Shyu et al., 2010). This approach is
of particular interest to occupational therapists as it takes place in the childs environment, focusing on the childs occupations, such as play or activities of daily living

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Play Strategies and Autism

(Case-Smith & Arbesman, 2008). The DIR/FloortimeTM model involved intervention entirely with caregivers of children with ASD. It is designed to assist children
with ASD in developing social, emotional, and intellectual capacities and establishing relationships with people. DIR/FloortimeTM refers to the action of caregivers
or parents get down on the floor and playing with their child for a period of time.
Caregivers or parents are instructed to follow the childs lead during play sessions
and attempt to extend what the child does to elicit reciprocal interactions as many
as possible. Greenspan and Weider (1997) recommend conducting six to ten 2030min FloortimeTM sessions per day during play time or activities of daily living.
Other studies have reported that children with ASD and their families may benefit from the DIR/FloortimeTM approach (Dionne & Martini, 2011; Greenspan &
Wieder, 1997, 2005; Mahoney & Perales, 2003; Pajareya & Nopmaneejumruslers,
2011; Solomon et al., 2007; Wieder & Greenspan, 2003). Children with ASD have
been reported to make significant gains in emotional development and to decrease
stereotyped behaviors. However, the majority of the studies used convenience sampling rather than randomized sampling and did not include a control group (Dionne
& Martini, 2011; Greenspan & Wieder, 1997, 2005; Mahoney & Perales, 2003;
Solomon et al., 2007; Wieder & Greenspan, 2003). Only one study was a randomized controlled trial that used reliable and valid outcome measures (Pajareya &
Nopmaneejumruslers, 2011).
Pajareya and Nopmaneejumruslers (2011) replicated the study of Solomon et al.
(2007) and used the Functional Emotional Assessment Scale as the outcome measure for the treatment effect on children with ASD in Thailand. The results showed
a positive effect of the DIR/FloortimeTM intervention in promoting emotional functioning suggesting that intervention could be effectively replicated in different cultural settings. A limitation of the study was that the treatment group received a
varying amount of intervention.
In addition to supporting the development of children with ASD, interventions
that involve training parents to interact with their children yield positive effects
(Blackledge & Hayes, 2006; Casenhiser et al., 2013; Moes, 1995; Sofronoff & Farbotko, 2002). Children with ASD were involved in interactions with their parents and the quality of the parentchild relationship improved. For example, Moes
(1995) reported that parents of children with ASD used strategies to manage childrens difficult behaviors and experienced relatively less stress after participating
in a parent-training program.
Only one case report has been published regarding the effectiveness of the
DIR/FloortimeTM intervention model in Taiwan (Yen et al., 2008). Two psychologists implemented this approach in a clinical setting for two preschool children
(46 and 54 months old) with high-functioning autism. These children received 12
and 10 1-hr weekly treatment sessions, respectively. Intervention outcomes were
primarily assessed by the researchers qualitative observations and did not directly
involve caregivers and families.
The purpose of this pilot study was to investigate the effects of home-based
DIR/FloortimeTM intervention program on increasing the social interaction and
adaptive behaviors of children with ASD. Accordingly, this single group and preand posttest design addressed the following questions: (a) Does the home-based

Liao et al.

DIR/FloortimeTM intervention program increase the social interaction and adaptive behaviors of preschool children with ASD? and (b) Do mothers perceive a
reduction in their stress levels after undergoing parentchild intervention training?
METHOD

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Participants
Eleven boys (mean age: 55.9 months; age range: 4569 months) and their mothers (mean age: 35.7 years; age range: 2944 years) were recruited as participants.
The National Cheng Kung University Hospital internal review board approved the
study. Participants were recruited from the hospital clinic, private clinic, and the
early intervention centers through the distribution of research fliers. Written informed consent was obtained from the parents before enrolling their child in this
study.
None of the mothers had previously participated in training that incorporated
the DIR/FloortimeTM model. The childrens nonverbal intelligence quotient (IQ),
evaluated using the Leiter International Performance Scale-Revised (Roid &
Miller, 1997), varied from 67 to 122 (mean: 101.6; SD: 17.8). All of the children
had been diagnosed with an autistic disorder by a mental health professional according to the Diagnostic and Statistical Manual IV Text Revision (DSM-IV-TR)
criteria (APA, 2000). The severity of disability was based on a combination of the
childrens verbal IQ scores (Wechsler Intelligence Scale for Children) and levels of
functional language and social adaptation (based on clinical observation or behavioral and adaptation scales). Additional characteristics of the sample are presented
in Table 1.
Measures
Demographic information. The demographic characteristics of the children included age, gender, diagnosis, severity of disability (mild to profound). The demographic characteristics of the mothers included age, gender, education level (no
schooling/elementary school to graduate school), marital status (single, married, or
otherwise), and employment status (full-time, part-time, or unemployed). These
data were obtained at the beginning of the first session.
Functional Emotional Assessment Scale. The Functional Emotional Assessment
Scale (FEAS; Greenspan et al., 2001) was used to measure changes in the childrens
emotional functioning within the context of the relationship with their caregiver.
The FEAS is a valid and reliable rating scale that can be used when observing videotaped interactions between children with ASD and their caregivers (Greenspan
et al., 2001). The FEAS is based on six functional developmental levels: (a) selfregulation and interest in the world; (b) formulation of relationships, attachments,
and engagements; (c) two-way, purposeful communication; (d) behavioral organization, problem solving, and internalization; (e) representational capacity; and
(f) representational differentiation. Each capacity can be rated on the 0 to 2 rating scales. Ratings for items are summed to obtain subtest scores as well as a total
test score. Higher FEAS scores indicate superior functional behavior and a higher
developmental level.

Play Strategies and Autism

TABLE 1. Characteristics of Children with Autistic Spectrum Disorders and their Mothers
(N = 11)

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Variables
Child with ASD
Mean age (months)
3648 months
4960 months
6172 months
Gender: Male
Severity of disability
Mild
Moderate
Mean nonverbal IQ
Mothers Caregivers
Mean age (years)
Level of education
Senior high school
Bachelors degree
Masters degree
Marital Status: Married
Employment Status
Unemployed
Part-time/Full-time

M (SD) or n (%)

55.9 (8.9)
4 (36.4%)
3 (27.3%)
4 (36.4%)
11 (100%)
3 (27.3%)
8 (72.7%)
101.6 (17.8)
35.7 (4.2)
2 (18.2%)
8 (72.7%)
1 (9.1%)
11 (100%)
6 (54.5%)
2 (18.2%)/3 (27.3%)

Two 15-min childcaregiver interactions were videotaped for each child immediately before and after intervention. Two trained occupational therapists were asked
to independently rate each childs emotional functioning from the videotapes. The
therapists had experience in assessing children with ASD and were unaware of
whether they were viewing the pre- or posttest. Interrater reliability between the
two occupational therapists was examined for all 11 children. The intraclass correlation coefficient was 0.85 (95% confidence interval: 0.530.96) for pretest ratings
and 0.94 (95% confidence interval: 0.810.99).
Vineland Adaptive Behavior Scales. The VABS-II (Sparrow et al., 2005) was
used to identify changes in the childrens adaptive behaviors. This scale covers
the domains of communication, daily living skills, socialization, and motor skills.
Higher scores indicate greater skills. Reliability was established above the 0.80 level
for all domains (Sparrow et al., 2005). A Chinese version of the VABS-II has been
published and validated for use in a Taiwanese population (Wu et al., 2004). Cronbachs alpha coefficients for the sample at the pre- and posttest exceeded 0.85 for
all domains.
Parenting Stress Index-Short form. The Parenting Stress Index-Short Form
(PSI/SF; Abidin, 1990) was used to assess mothers perceptions of stress. This index comprises 36 items and yields a total stress score from three subscales: parental
distress, parentchild dysfunctional interaction, and difficult child. Each item was
graded on a five-point Likert scale. Higher scores indicate greater perceived stress
among mothers. The Chinese version of the PSI/SF exhibited satisfactory reliability and construct validity (Weng, 1995). The Cronbachs alpha coefficients of the
sample at the pre- and posttest exceeded 0.70 for all subscales.

Liao et al.

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Intervention Program
The intervention program was based on the principles of the DIR/FloortimeTM
intervention developed by Greenspan and Wieder (1997). The first author, an
occupational therapist, provided instruction to all families on implementation of
the DIR/FloortimeTM intervention. Prior to the study, the first author studied
the DIR/FloortimeTM model from books (Greenspan & Wieder, 1997; Interdisciplinary Council on Developmental and Learning Disorders [ICDL], 2009) and a
DVD lecture of the PLAY (Play and Language for Autistic Youngsters) Project
model. In addition, she underwent 25 hr of structured, intensive, and supervised
training in the DIR/FloortimeTM model provided by an experienced therapist who
certificated from the ICDL.
The Figure 1 presents the process. Before the first session, each mother individually attended a 3-week one-on-one training course at research laboratory with the
first author, to learn about the DIR/FloortimeTM model. Mothers also attended a 3hr DVD lecture presented by the first author. The lecture consisted of the basic concepts of the DIR method and play strategies. During each one-on-one session, the
mother was trained in the home-based DIR/FloortimeTM intervention program for
2 to 3 hr and set individualized goals for her child. To achieve the identified goals,
the mothers were trained to observe their childs cues, follow the childs lead, and
implement the play strategies that were appropriate for their childs current level
of functional development.

FIGURE 1. The process of the DIR/FloortimeTM intervention program.

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Play Strategies and Autism

At the beginning of the intervention program, each family received a manual

to facilitate the application of play strategies to daily activities. The mothers were
asked about their goals and discussed them with the first author. Specific goals and
a home program were established according to the results of evaluation and childrens age and development for each family. The mothers were instructed to conduct the home-based DIR/FloortimeTM intervention program for at least 10 hr per
week. In addition, the first author met with the mothers and children every 2 weeks
to discuss concerns regarding the intervention program or difficulties experienced
by the parents or children. All of the mothers completed the 10-week intervention program. The average number of intervention hours for all participants was
109.7 (SD = 38.0, [85152]). Each child with ASD was instructed to continue his
routine programs, including special or preschool education, speech therapy, or occupational therapy.
Data Analysis
SPSS 17.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze the data. Descriptive statistics were computed for demographic data, independent variables,
and outcome measures. Wilcoxon-signed rank tests were performed to examine
changes in the childrens emotional functioning and adaptive behaviors, as well as
differences in the level of parental stress. The level of significance was set at p <
.05. An effect size index r was established on the basis of the z score divided by the
square root of the total sample (low effect size: 0.30 > r 0.10, medium effect size:
0.50 > r 0.30, large effect size: r 0.50; Cohen, 1988).
RESULTS
Functional Emotional Assessment Scale
Mean scores for the overall FEAS and the six FEAS domains increased over the
10-week intervention (Table 2). The effect size for the total score was 0.49 and varied from 0.30 to 0.58 for the six domain scores (medium to large effect). Differences
were significant for the total score (Z = 2.31, p < .05) and the domains engagement and relating (Z = 2.44, p < .05), two-way purposeful emotional interaction
(Z = 2.70, p < .01), and social problem solving (Z = 2.50, p < .05).
Vineland Adaptive Behavior Scales
The effect size for the VABS-2 varied from 0.43 to 0.52 (medium to large effect)
except for motor skills (0.21) (Table 2). There were significant improvements in the
total score (Z = 2.19, p < .05) and the domains communication (Z = 2.02, p <
.05), daily living skills (Z = 2.45, p < .05), and social (Z = 2.09, p < .05).
Parenting Stress Index-Short Form
The effect size was small for the change in total score (0.27) and subscale scores
for parental distress (0.17) and difficult child (0.27). There was a significant (Z =
2.11, p < .05) decrease in the parentchild dysfunctional interaction score; the
effect size was medium (0.45) (Table 3). The latter finding indicates that mothers
perceived greater positive parentchild interactions following the intervention.

Liao et al.

TABLE 2. Changes in Functional Emotional Assessment Scale and Vineland Adaptive

Behaviors Scales by Children with ASD

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Measure
Functional Emotional Assessment Scale
Total Score
Self-regulation and interest in the world
Forming relationships, attachment, and engagement
Two-way, purposeful communication
Behavioral organization, problem solving, and
internalization
Representational capacity
Representational differentiation
Vineland Adaptive Behavior Scalesecond edition
Total Score
Communication
Daily Living Skills
Socialization
Motor Skills

Statistics

Pretest
M (SD)

Posttest
M (SD)

Effect Size

30.6 (13.6)
10.5 (2.6)
7.4 (3.4)
4.2 (2.3)
1.6 (1.2)

39.8 (16.8)
11.9 (3.1)
10.6 (4.7)
5.7 (2.4)
2.5 (1.1)

< .05
0.12
< .05
< .01
< .05

0.49
0.33
0.52
0.58
0.53

5.0 (3.6)
2.1 (2.3)

6.0 (4.1)
3.1 (2.9)

0.28
0.16

0.23
0.30

154.3 (56.9)
43.5 (17.9)
52.4 (25.2)
21.2 (10.9)
37.3 (9.6)

173.5 (65.1)
48.0 (20.5)
60.7 (24.4)
25.8 (15.3)
38.9 (10.2)

< .05
< .05
< .05
< .05
0.33

0.47
0.43
0.52
0.45
0.21

DISCUSSION
There are several limitations that are important to consider when interpreting the
results. This was a single group design and, therefore, the effect of maturation and
other services and supports were not controlled. In addition, the mothers were a
sample of convenience who expressed interest in their children receiving additional
services. They may not reflect the attitudes and beliefs of all mothers of young
children with ASD.
The results provide preliminary evidence of the effects that the home-based
DIR/FloortimeTM intervention program have on increasing the social interaction
and adaptive behaviors of children with ASD in Taiwan. This research provides
three main findings. First, children made significant improvements in two-way purposeful communication, forming relationships, behavioral organization, and problem solving following the home-based DIR/FloortimeTM intervention program.
The effect size varied from medium to large. Second, the adaptive functioning of the
children improved, especially communication and daily living skills. The effect size
varied from medium to large. Third, the mothers perceived positive changes in their
parentchild interactions after implementing the home-based DIR/FloortimeTM intervention program.
TABLE 3.

Changes in Parenting Stress Index: Short Form by Children with ASD (n = 11)

Measures
Total score
Parental distress
Parentchild dysfunctional interaction
Difficult child

Statistics

Pretest
M (SD)

Posttest
M (SD)

Effect Size

106.9 (11.8)
37.3 (7.1)
32.6 (5.3)
37.1 (6.4)

100.0 (15.0)
35.9 (6.1)
30.0 (5.6)
34.1 (7.1)

0.21
0.41
< .05
0.20

0.27
0.17
0.45
0.27

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Play Strategies and Autism

Consistent with the results of previous studies (e.g., Pajareya & Nopmaneejumruslers, 2011; Solomon et al., 2007), we found that training in the home-based
DIR/FloortimeTM intervention program was effective for enhancing the development of children with ASD. In our study, the average total FEAS score increased
from 30.6 to 39.8, a medium effect size. Our findings correspond to those of a similar to 3-month study conducted in Thailand (Pajareya & Nopmaneejumruslers,
2011). The intervention period in our study was shorter (10 weeks) and less intense
(average of 10 hr per week) compared with Pajareya and Nopmaneejumruslers (average of 15.2 hr for 3 months). The results are encouraging because they suggest
that interventions performed by mothers at home can be effective.
Our results indicate that the children made significant gains in adaptive skills.
Notably, many related studies (e.g., Klin et al., 2007; Szatmari et al., 2003) have focused primarily on the socialization and communication, and have overlooked the
daily living skills (Jasmin et al., 2009). Few interventions have been designed to target daily living skills. In our study, children with ASD achieved functional improvements in their daily living skills over the 10-week intervention. Greenspan and Weider recommended that caregivers execute six to ten 2030-min DIR/FloortimeTM
interventions per day during play time and activities of daily living (Greenspan
& Wieder, 1997). The home-based DIR/FloortimeTM intervention program developed in this study satisfied this recommendation and equipped mothers with strategies for cultivating childrens functional and developmental skills.
In Chinese, the parentchild relationship is embedded in a hierarchical family
structure. Interactions between parents and children are connected to the notion
of parental control and governance (Wu, 2013). We observed that the mothers perceived improvements in their parentchild interactions after the intervention. The
mothers in this study were taught how to play with their children in a natural environment. Many of the mothers reported that they did not know how to play with
their child at the beginning of the study. By contrast, after completing the training,
they were confident and eager to play with their children. These observations suggest the importance of collaboration with mothers of children with ASD on strategies for play.
Nevertheless, no significant improvements in the subscales of Parental Distress
or Difficult Child were observed. According to Abidin (1990), parental distress
reflects complex aspects, including perceptions of child-rearing competence, conflict with a spouse or partner, social support, and stresses associated with restrictions placed on other life roles. The subscale Difficult Child reflects the caregivers
view of a childs temperament, noncompliance, and demands. Changes to these
subscales might not be noticeable in a short intervention period. Several studies
have suggested that mothers of children with ASD experience high levels of distress, and that the sources of parental stress are confounding factors (Mori et al.,
2009; Tomanik et al., 2004). One possible explanation is that the intensive interventions and consultations support provided every 2 weeks in this study primarily
focused on improving the interaction between parents and children and the acquisition of play skills. Accordingly, the mothers perceived substantial changes in their
parentchild interactions. Further research is recommended to identify strategies
for reducing parental distress related to behavioral problems of children with ASD.

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10

Liao et al.

With respect to implications for practice, the results are useful for occupational
therapists to assist mothers to carry out the home-based DIR/FloortimeTM intervention program for children with ASD in Taiwan. Therapists could involve mothers in direct treatment in order to coordinate center/hospital and home programs.
Further research including randomized controlled trials is needed to substantiate
the results of our study with greater number of participants. We could not control for the effects of normal development, and certain confounding factors (such
as family environment, maternal personality traits, etc.). Consideration should be
given to including covariates such as severity of ASD symptom and mothers wellbeing and interactions when analyzing outcomes.
CONCLUSION
This study provides preliminary evidence of the effectiveness of a 10-week homebased DIR/FloortimeTM intervention program for preschool age children with
ASD and their mothers. Children made significant improvement in emotional functioning including two-way communication, behavioral organization, and relationship forming. Furthermore, their adaptive functioning improved, especially in communication and social skills. Further research, including randomized controlled trials, are recommended to determine the effectiveness of DIR/FloortimeTM intervention program in improving social interaction and adaptive behaviors of preschool
children with ASD.
ACKNOWLEDGMENTS
Support for this research was provided by the Taiwan Ministry of Education under
the NCKU Aim for the Top University Project for Promoting Academic Excellence & Developing World Class Research Centers. We thank all the families that
participated.
Declaration of Interest: The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of this article.
ABOUT THE AUTHORS
Shu-Ting Liao, M.S., Yea-Shwu Hwang, Sc.D., and Ling-Yi Lin, Sc.D., Department
of Occupational Therapy, College of Medicine, National Cheng Kung University,
Tainan, Taiwan. Yung-Jung Chen, M.D., DMSci, Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. Peichin Lee, Ph.D., School of Occupational Therapy, Chung Shan Medical University,
Taichung, Taiwan. Shin-Jaw Chen, M.D., Dr. Yins Clinic, Tainan, Taiwan
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Play Strategies and Autism

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