Combining DIR/Floortime and Sensory Integration

This week I welcome back Stephanie Peters and a new guest, Courtney St. Germain. Both are Occupational Therapists who are Expert DIR/Floortime Training Leaders at ICDL’s DIR Institute in Livingston, NJ where Courtney is the Program Director. We are discussing their Continuing Ed. article “Combining DIRFloortime and Sensory Integration for Children With ASD” that was published in AOTA in January, the American Occupational Therapy Association‘s OT Practice magazine. The article focuses on sensory modulation and how combining DIR/Floortime and sensory integration treatment promotes social-emotional development.

The Impetus for the Article

Courtney explains that as Occupational Therapists (OTs) first, they had to keep in mind that other OTs may not have heard of DIR/Floortime, even though Courtney and Stephanie intuitively include it in and find it hard to separate from their practice. They wanted to present how DIR/Floortime supports sensory integration. When they got into the research, they discovered that sensory integration research was showing improvements in many areas, except in that of emotional reactivity. Sensory integration is already play-based and fun, and seeks those adaptive behaviours, but you can do all of that without attuning to those emotional responses, and DIR does that quite nicely, Courtney asserts.

Stephanie continues that OTs can respond to emotional reactivity differently. When a child is fearful, unhappy or scared, the tendency is to push through it or force the interaction with the idea that the child needs to get used to it, experience it, and learn to cope with it, Stephanie continues. This tends to cause a fracture in the relationship and more anxiety.

In Floortime we have the permission to stop in that moment, engage with that emotion, and see where it can take you. They wanted to send this message to other OTs: that there is another way to do this practice and have stronger outcomes for the child and family. Courtney adds that there’s also always the expectation to show therapeutic progress and achievement of goals. During those pauses of ‘being‘ and ‘attunement‘ in Floortime, you can feel like you’re not doing ‘enough’. There’s value in this pause and sitting in this ‘icky’ moment of emotional dysregulation, Courtney explains.

The Role of Emotions in Sensory Integration

On last week’s podcast, Keith Landherr focused on that emotional regulation and co-regulation piece that is essential in any sensory integration treatment. Stephanie says that this was a large part of this article, too. As Occupational Therapists, they know that there’s “an emotional tag to every sensation“. A child will bring an emotional response to an interaction to sensory input and as Floortimers who are promoting social-emotional development, they ask themselves, “How do I respond to that emotion” and “How do I see it as an opportunity to co-regulate to enhance engagement?” which then allows you to continue up the developmental ladder in an interaction.

Stephanie says that when you’re working with anybody, you want to support the foundation, which is why this paper focused specifically on the first three Functional Emotional Developmental Capacities in the DIR model. You want to have a strong foundation before you build off of it, she continues. Whenever we’re engaging with anybody, it always comes back to the first three capacities where we really want to spend time. Emotions come in every capacity, but how we respond to them within the first three really sets the stage for how much we can build off of it in the later ones, and how many more connections we can build off of them, and how complex we can make them. But if we’re not strong in the beginning, we can’t get there, Stephanie explains.

Relationship is about Trust

It’s so important to acknowledge what the child is feeling and experiencing to maintain trust. If you push them through something they are uncomfortable doing, you lose that trust and threaten the relationship you’ve established. Stephanie says that we want children to be intrinsically interested in interacting with the people in their environment rather than it coming from an imposed request or demand. We all need to process our emotions before we can move on. Floortime gives you the gift to have that shared experience where someone can co-regulate with you, she adds.

You can set that space and comment, “Oh, that looks like it was really hard” or “That was really scary” or “You don’t really like this” or “No way do you want to do this. Ok. I hear you.” Once you can hold someone in that space, all of a sudden, regulation improves, the situation is de-escalated, they are more emotionally available to think through the situation. Validate, validate. This comes first. Stephanie adds that when others are watching and know there are goals to be met, you can say, “This will help us to get there, and this is the most important thing right now.“

Sensory Modulation

Courtney offers that sensory modulation is one component of sensory processing. Her and Stephanie felt the need to focus on it in their article because it sets the foundation for the rest of sensory processing. Courtney gives the example of being ok with tags on her clothes. She said she can have empathy, though, for kids who do have tactile sensitivities to tags on their clothes. Or when children are about to get on a swing they might have a fear response. She would want to accommodate her clients’ sensitivities by wondering if it’s too high, if it’s makes their bodies uneasy, etc. rather than push through to get that adaptive response.

Instead, Courtney says she would want to support and attune to what she’s seeing and facilitate the experience of the child getting on the dynamic equipment. I asked what they would do, though, if the child isn’t really interested in ‘sitting in that moment’ with the discomfort and distracts you out of it? Stephanie says that’s where the FEDCs come in. Depending on where they child is developmentally, you use that as your guide. If they are uncomfortable let’s think about the first capacity of regulation and focus on co-regulation: Do I need to validate? Do I need to stop the swing and hold them in the space of, “Ooo…that didn’t feel so good“?

Once you co-regulate and the child is attending with you again, you have engagement where you connect. Maybe the child is still a little bit sad, Stephanie continues, but you’re in that space together. And then maybe you can get to capacity 3 where you have back-and-forth exchanges, recognizing their state with affect, “Uhh…” where they have the same facial expression and you can go back and forth with that emotional response. Once that foundation is there, you might reach capacity 4 where you wonder, “What do we do now?” Do we get off the swing? Do we try again? Do we throw the swing away? Where do we go from there?

It’s child-led and it’s child-directed. It almost happens naturally, Stephanie explains. While Ayres Sensory Integration is child-led, Courtney continues, sensory modulation is only one part of the S.T.A.R. Institute’s nosology for sensory processing. If the child is uncomfortable in a particular position, that is another piece of sensory processing which all links back to sensory modulation. If the child is struggling to integrate all of those sensations at the same time and Courtney sees fear, slouching, fatigue, or a fight response, she can understand as an OT that the postural control is being impacted by the child’s ability to modulate those senses. 

DIR/Floortime as the Missing Piece

This is why they chose to write about the sensory modulation piece, Courtney says. The more they, as an OT, can attune to the sensory modulation differences, the more they can support the postural pieces, and the developmental capacities. DIR/Floortime helps Courtney integrate all of the information that is meaningful to the child so they can find joy together. You know that it’s working when the child is having fun, she says. Those adaptive responses are happening as a result because you are having an attuned relationship and also getting the sensory integration that the parents are coming in for. 

Stephanie loves that this is such a stark difference to the relationship or therapeutic consequences and how much you miss out on as a clinician if you see it more behaviourally, thinking the child is being difficult or they don’t want to do it. Then you end up forcing it, she explains, which causes a disconnect between you and the child. As a therapist, you also lose the ability to think about their sensory processing and why they are giving you that emotional response.

Sensory Discrimination

Discrimination is the ability to interpret sensory information through space and time. For example, if your eyes are closed, your proprioceptive sense body awareness discrimination allows you to touch your nose without your visual system helping. But if you don’t have an understanding of that first modulation piece, it’s going to impact all of the other things that come after it. That’s the root of sensory processing, Courtney explains. It’s your ability to interpret the intensity of the sensory experience.

Similarly, she continues, if I’m not allowing for touch because it’s an overwhelming sensory experience, I’m losing out on experiences that are going to help me refine my discrimination through touch. If I’m avoiding grass, dirt, or fleece, for example, I’m not going to have those experiences to build upon so it’s impacting the sensory discrimination. And that can happen for any of our sensory systems.

Our Children under Scrutiny

I brought up how comical it is that everyone doesn’t get Occupational Therapy since we all have sensory experiences that overwhelm or underwhelm us. As neurotypical, we never address them unless there is an injury that requires us to see an O.T. yet our children are scrutinized endlessly when they show sensory sensitivities. We can all get overwhelmed when we’re stressed, tired, or not feeling well by too much noise, for instance. We can ask a family member to turn the TV down, we can leave the room, or we can have a moment of rage.

Awareness of Sensory Processing allows for Co-Regulation

Our ability to regulate in the moment and modulate that sensation in the moment is our goal. We are all sensory beings. This should be normalized so we understand that the sensory environment affects all of us in different ways. Having the attunement and helping our children modulate their sensations gets us to the next capacity of engagement, Courtney offers. Stephanie adds that it’s difficult and confusing for parents to grasp what’s happening to their child when they get so dysregulated. An O.T. can help you identify the sensory processing modulation difficulties, and then do something about it.

Even as adults when something doesn’t feel right and we’re uncomfortable it’s not fun. But within a safe relationship, someone can say to us that we’re hungry and tired, and it’s late at night so let’s turn off the TV and get you a snack. Courtney adds that this allows us to reframe what a behaviour means, what the intent is, and to see it as communication. As O.T.s, they’re going a bit deeper to see what causes that dysregulation. But at the end of the day, if you’re not an O.T., you can still attune rather than get frustrated, and this softens us.

It allows us to stay regulated enough to problem-solve and empathize, “If I were them, what would I need right now?” This process and relationship piece is incredibly valuable. Then you can figure it out together rather than get into a power struggle.

Bringing Parents On Board

I asked how they help parents in this process, especially if they find constant dysregulation disruptive to their life and they don’t want to take the time to pause and attune every time. Perhaps they are uncomfortable sitting in that discomfort themselves and have trouble tolerating strong negative emotions. Stephanie likes the analogy that you can’t teach a child how to blow their nose when they have the flu. It’s impossible to practice this process in the moment. 

It’s our ultimate goal to be able to do this in the moment, but practicing validation and attunement when things are calm will prepare you best, through Floortime. Maybe you start by commenting on positive emotions like, “Wow, you are really excited“, Stephanie offers. I pointed out that commenting over questions puts so much less pressure on the child as well. Rather than asking, “What’s wrong? What are you feeling? Tell Mama!” you can comment, “Oh it looks like that is really hard for you” or “It looks like you are having a hard time.“

Courtney suggests that we need to empathize with parents, saying, “This is really hard.” If you’ve experienced many years of huge meltdowns and you’ve tried everything you can to console your child, you’re going to have moments where you snap because that’s just human. This sensory modulation and regulation piece is for everybody, she continues. You can comment to the parent that in that moment, you were not able to regulate your own self. Who around you can offer you co-regulation which can be especially difficult during Covid. 

Calming the Storm

Video review can also help, Courtney asserts. In this moment, what was the cue that your child might be feeling dysregulated? We won’t catch it every time, but next time, what can we observe to anticipate that they won’t be able to modulate if one more thing gets added to their cup. Helping parents to connect those dots has opened up conversations where parents confess that they feel helpless when they cannot help their child and then allows them to work through the process of offering them that support and help.

Fixing a Problem versus Creating the Space to Wonder

I put Courtney and Stephanie on the spot by asking about a struggle my son has been having at school when he calls his friends names from Mario Kart. He’ll say, “Johnny, you’re Koopa Troopa!” and then laugh, for instance. He is not intending to be dysruptive and loves playing with these friends. There is no ill intent. But it is disruptive and it dysregulates his friends who won’t want to be called a name other than their own. 

I took away from this podcast that perhaps he’s been sitting too long in class and he needs more core support because it’s hard to hold up his core for an extended period of time. Courtney and Stephanie both nodded. I offered that perhaps he is bored while he is waiting for other children to finish a task. He struggles with waiting. Stephanie says, yes, I’ve started to answer my own question and she loves the difference between having a problem to fix or solve and creating the space to wonder.

In the moment it’s difficult to wonder what modulation system is being affected, so you might slow down and comment that the other child seems sad and drawing attention to the child’s face. Afterwards you can certainly wonder about what he was communicating and then why. Something wasn’t right. I responded that this is helping a bit because he is able to sometimes say that he feels like calling his friends video game names before it happens, so we can intervene. But I wondered whether we might focus on his own regulation?

We could say, “Hmm… something’s hard for you.” “I wonder what’s going on with you?” to keep my son in the moment and try to peak his self-awareness. Courtney likes this direction and said the first thing that came into her mind was that he must really love Mario Kart! He must have a really strong emotional connection to those characters to use it as a means to his own regulation is a huge strength. Bringing it to another child is promoting empathy, which is higher up on the developmental capacities. The root of this is his own regulation, though. It’s our clue that something is going on here.

Is it his posture? Does he need to get up and move around? Does he need another activity because he’s bored? Or you could see it as a way to connect with the other kids. He wants to share his love of Mario Kart with others. What is his body telling us in that moment, and from a modulation standpoint, the more people there is in the room the noisier it is, the more noises he has to filter. It might be closing off some of the inputs. When someone is bubbling over, we need to provide less: less sound, less movement, etc.

Even the expression of “Oh, look at that child’s face” is adding more input which might be too overwhelming in the moment or cause escalation. Do we need to do less in the moment or more to re-regulate? At the end of the day, it’s about engagement. If we aren’t connecting with others in a way that’s meaningful to both parties, it’s not shared. I also added that it might run the risk of being routine if he name calls, we draw attention to the other’s face. He repeats, “He’s angry” but doesn’t really process what it feels like to be angry.

My last question was about how you take that break by removing him from the classroom without it being a ‘punishment’ of sorts, implying that he was ‘bad’ and has to leave? Courtney said she would highlight the detail in what they’re seeing. She would say, “Oh, your body is getting a little wiggly. You need a break.” and connecting that observation with the emotion of “maybe you’re bored” or “maybe you’re frustrated” or “maybe you’re excited“. I continued, “maybe you can’t wait to play with your friends and I can’t wait until we finish this math exercise to play!“

Stephanie adds that we can wonder if it comes from a place of praxis. Does he know what he should be doing next? If so, we need to help support with an idea. Is it coming from a place of decreased postural control and fatigue? If so, we know he might need a break and know that we have to limit the amount of time that he has to sit in advance. Giving the child options of what they might need next in the moment should come from a place of knowing that child’s profile and knowing his likes and needs rather than trying out a sensory technique because the child is ‘wiggly’.

Thank you to Stephanie and Courtney for sharing their insights from their latest publication and for applying this knowledge to a real-life classroom situation. It was a great compliment to our last podcast. You can learn more about ICDL’s DIR Intensives at the DIR Institute and the DIR Home Program at ICDL’s website. Please consider sharing this post on Facebook or Twitter and feel free to share any relevant comments, experiences, or questions in the Comments section below.

Until next week, here’s to affecting autism through playful interactions!