DIR/Floortime and Physical Therapy

by Affect Autism

This Week’s Guest

Mary Beth Crawford is a licensed Physical therapist and Developmental, Individual differences, Relationship-based (DIR) Expert Training Leader who founded Baby Steps Therapy in 2008. Mary Beth regularly provides lectures and in-service training to numerous parent groups, and medical professionals and allied health groups on the foundations of motor development, and on her unique approach to pediatric physical therapy. She is here to talk about how she practices Physical Therapy within a DIR/Floortime approach.

Mary Beth was mentored by Occupational Therapist Maude Le Roux early in her career, who introduced her to DIR/Floortime. It gave her the science to the instincts she always had about development, individual differences, and relationships. Her lofty goal is to bring the Floortime approach to more developmental pediatric physical therapists. In PT they have affect, sensory and motor. All of these synchronously develop together to optimize a child’s motor development, Mary Beth states.

Bonus Insights

What is Physical Therapy?

Physical Therapy (PT) is a broad profession that involves extensive training in the musculoskeletal, neuromotor, and respiratory systems. In continuing education you can specialize in orthopedics, acute care, etc. and for Mary Beth her interest was in pediatric physical therapy and development. The goal is to optimize any individual’s function and activities of daily living. For kids, their outcomes have to do with play and engagement and to be able to access everything around them in their environment.

How is it Different from Occupational Therapy?

I asked Mary Beth about how PT relates to motor planning that falls under occupational therapy and how PT and OT overlaps. There is a large overlap, Mary Beth states. Both should take into account all of the individual differences of a child, she continues. Traditionally, the PTs would focus more on gross motor while the OTs would focus on fine motor development. Mary Beth collaborates with an OT at her clinic and they look at the whole child and the whole body. OTs are looking at the core, the postural control, and the motor development. The PTs can’t discount when the visual and the vestibular systems are impacting near-point eye co-ordination, for instance.

OTs tend to have a bit more background in developmental psychology whereas PTs have tended to have more training in the physical scope. Motor development as a PT for Mary Beth is focused on the individual differences. It’s paramount to how they’ll support a child to support their overall function. She would love for their to be more developmental PTs because Floortime marries PT so well, she believes.

What Brings a Child in for Physical Therapy?

I gave the example of how my son received physical therapy for his tippy toe walking. They needed to keep his heels down because if he were to stay up on his toes, his range of motion in his calves could restrict his growth. He wore orthotic boots to force his heels down. Looking back with a Floortime lens, I don’t like the idea of forcing the heels down when he had fun, squeaky shoes that would see him heel walking to hear the fun noises.

Mary Beth says that every child is unique and there’s a wide variety of what impacts toe walking. PTs look at the muscles and flexibility. When muscles get tight, it tethers our proprioceptors and can impact our body awareness. When kids go up on their toes, they often don’t get trunk rotation, which can be a function of their visual and vestibular systems working together and staying stable. 

Sometimes children go up on their toes in a heightened state of arousal to stay regulated at the first Functional Emotional Developmental Capacity (FEDC). So, it can be hyperarousal or muscular skeletal tightness. They might also go up on their toes to get deep proprioceptive input. Mary Beth often thinks that children who have difficulties with their eyes working together, i.e., eye teaming, go up on their toes because the higher we are, the less our eyes have to converge. 

Kids might have an ease on their occular motor muscles if they’re up on their toes, which is a visual-spatial component. I explained to Mary Beth that my son was sent to a developmental optometrist who gave my son glasses because he was suppressing vision in one eye, and now his eyes are starting to work together. In my Floortime series, ‘We chose play‘, Occupational Therapist, Gretchen Kamke, pointed out how much my son loves to watch things move and he’s been that way since he was a baby.

Physical Therapy with a Floortime Lens

Mary Beth says there is value in the musculoskeletal component because some kids do develop orthopedic deformities from being high up on their toes, so it is prudent to consult about this. We won’t force a child if they’re upset, but if they have a range of motion and enjoy the orthotics, it can give them nice sensory input into their central nervous system and get their visual and vestibular systems working. When you don’t get your heel strike when up on their toes, you don’t have rotation which can impact bilateral integration and coordination, Mary Beth explains.

The brain and body need to be able to cross the midline to support their motor planning and praxis. So with orthotics, when there is heel strike in their gate, the activation chain goes right up to their trunk rotation, which supports their postural control. This of course is when there’s intentionality and understanding, not a refusal on the part of the child, Mary Beth explains. We want to support and not force because the latter sets off a fight or flight reaction in the child and that will prohibit any novel motor learning, Mary Beth says, if the child is not engaged and doesn’t have that intent.

I explained how the Floortime way to approach wearing orthotics is to find out something they’re interested in. My son loved Curious George, so they put Curious George’s image on the orthotics so we could talk up the ‘George boots’ and say, “I want a pair!” and make it enticing and fun for the child. Create that anticipation. Mary Beth says that in her clinic the children are engaged in the entire process of choosing a colour as well. In any way we can support a child’s affect and motor intent is the way to support it, Mary Beth agrees.

Mary Beth says she follows the child’s lead and interests, uses affect, gives the child agency, and understands that the orthotics are support meant to be used as a part of their entire program. She also understands their individual differences to also support their other sensory needs such as hyperarousal. I described how my son’s PT would bend his foot back to measure his range of motion to make sure it didn’t decrease as he aged. They would watch him walk back and forth, up and down stairs, etc. and was eventually discharged because he had no issues with tripping and falling.

There are ways to improve flexibility that don’t cause hypervigilance or resistance in our practice, and sometimes they take a lot longer, but I think that’s much more fruitful than stressing a young child’s system.

Mary Beth Crawford, Physical Therapist

Benefits of a DIR/Floortime Approach

Mary Beth sought a relationship-based approach was working with babies who had torticollis (tightness in the neck) and children with tightness in the heels and hamstrings. The philosophy was about improving the range of motion so the child wouldn’t have one-sided weakness. When she would go in to stretch and the Mom and baby would be crying, she would feel in her gut to instead do more gentle mobilizations like fascial release and started singing. The baby was more relaxed and Mary Beth could stretch the neck so much better when the baby was engaged

If the child is resisting, you’re just strengthening the tight muscle. Of course it’s easier said than done to get a child to sit and let you work on them, but with fascial release you can apply a pressure and it releases the tension. If you mobilize the first three Functional Emotional Developmental Capacities (FEDCs) of being regulating, engaging and relating, and having purposeful back-and-forth communication you can get so much more done as a therapist. I gave the example of the adorable video of the doctor who sang and was playful when giving a baby a vaccine. It takes patience, slowing down, intentionality, being in the moment and attuning to the child, and all the things we talk about in Floortime, like Kasheena Holder discussed last podcast.

Working With Parents

Mary Beth adds that a lot of times when she sees families, she’s validating the parent experience. Moms know and have instincts, she says. She wants to work together with the family. She wants them to feel comfortable to ask all the questions and know the goal, and how to get their while preserving joy, which is possible. This is the ‘R’ in DIR, the relationship. You spend that time at the beginning to form that relationship and reconnect.

The Foundations of Motor Development

When we’re looking at gross motor in development in a baby, one of the biggest things they look at is if they can hold their visual gaze on the horizontal when the PT displaces their body, Mary Beth explains. This is a foundational reflexive response that a child can use to lift their head to have prone extension control, which has to do with their gaze and the movement sense in their inner ear (i.e., their vestibular system). Then they roll, then they crawl and look down and up. All of these foundations are building information to the central nervous system and all of their sensory systems are developing, Mary Beth asserts.

Oftentimes, families will come with babies and Mary Beth’s team can support their sensory, affective and motor development. Sometimes they’ll get an older child that the school has referred who are working on catching and throwing or riding a bike. These are great goals, but it doesn’t mean you get there by just throwing a ball back and forth. Mary Beth says you first want to get on the floor and see if the child can roll a ball back and forth. Do they have the developmental capacity for the motor and the affect and the signalling at the foundation? Start scaffolding the skills from there. 

Once you can roll a ball back and forth, maybe you hit a balloon back and forth because it goes slow and it’s easier to see. Just like fine motor skills for writing are dependent on foundational gross motor skills, you have to go back to the foundation, Mary Beth says, in her work where gross motor is dependent on gaze stability and vestibular. A lot of kids who spin are trying to get more body awareness by staying in motion. Getting enough registration of the movement supports their gaze stability, she explains.

You can have better gaze stability when you’re on a swing or on a ball because the vestibular input supports the gaze for their ability, Mary Beth continues. Then on the swing the child can develop the reciprocity of affect cueing and emotional signalling while they’re moving because they can hold that gaze due to the movement. In Floortime, we presume competence for everybody, so first we work on the foundations of gaze stability and registering movement. Then the functional outcomes follow.

When the PT is concerned

I asked Mary Beth when she’s concerned with crawling, scooting, walking and lack thereof, or delays in each. Crawling is more of an important developmental stage than walking for Mary Beth because it is very sensory-based, being very tactile, giving proproceptive input and working on that visual-vestibular system. So if a child is not crawling, they tend to have weakness in their core, hips, or shoulders, or it goes back to their ocular motor visual system. If they are on hands and knees and their eyes aren’t working well together, but they come up on one side, they can see better, Mary Beth explains.

We ask the ‘why’ behind the behaviour, Mary Beth says. What is impacting the child not going through the developmental stages? As a PT, she approaches it the same way that Greenspan did for the social-emotional capacities in believing that all the stages can be supported. A child might have a hyper startle reflex that prevents rolling and crawling, so the PT wants to work on calming the central nervous system with affect cueing. There might be a tactile sensitivity. This is where the interdisciplinary approach with an OT is so helpful. Collaboration and communication is paramount to every family’s journey, Mary Beth says.


The Affect-Sensory-Movement Triad

With the Floortime approach to motor development, it’s important to become enagaged and know how the emotional and relationship piece impacts the motor development. It can go the other way too. The more kids can have movement and joy and fun, this movement piece and sensorimotor experiences can impact the sensory and emotional regulation. Movement activates higher brain centres and is so important for development. It can be a way to work on gross motor goals when the child is engaged with music or other things they enjoy.

Movement is Essential for Development

Hide-and-seek is a game where you can do anticipation and chasing, which is fun. The movement increases arousal, Mary Beth says. There are so many different ways to engage with movement whether it’s bouncing on a ball, or five little monkeys, or row, row, row your boat. For some kids movement can be dysregulating, but that can be an opportunity for growth, Mary Beth adds. You just have to figure out how to attune and scaffold movement. How much movement can you get while being engaged? Start swinging in a blanket gently, for instance. Titrate the movement up slowly. 

It’s all relationship-based. Kids don’t reach for the bell, they reach for your face, Mary Beth says Dr. Greenspan would say. When you kick a ball, it’s relational, she says. As kids change and grow and develop, their nervous systems change and can go from being scared of movement to loving roller coasters, Mary Beth says. As things are scaffolding, we’re attuning and always raising the bar to continue to support one another and maximize their developmental growth. It’s about getting the movement registered in the central nervous system to support the Functional Emotional Developmental Capacities (FEDCs).

Movement is important in impacting the developmental capacities in that inverse way. Kids have to have a capacity to emotionally signal and affect cue with that gaze stability. They might need to have a lot more movement to be able to get that affect cueing required at the foundational capacities to get to the higher capacities. The key is remembering that even though your goals are motor development, we’re taking in everything in supporting that motor development. The pacing that we can provide cannot be underestimated at all. 

We need to ground ourselves, trust our instincts and support and give the child the space and time to generate their own development.

Mary Beth Crawford, Physical Therapist

This week’s PRACTICE TIP:

This week let’s notice if our children compensate in their movements for what might be a vulnerability in part of their sensory system.

For example: If your child moves a lot, are they able to engage with you much better while on a swing? If your baby is not yet walking, are they crawling on all fours and able to roll over? Try getting that affective engagement with them while helping with these movements.

Thank you to Mary Beth for providing such valuable information on how she impacts a child’s motor development by taking a holistic approach using DIR/Floortime to look at overall development of the affect, sensory, and motor systems. I hope that you learned something valuable and will share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. Stay tuned for the next podcast in two weeks.

Until next time, here’s to choosing play and experiencing joy everyday!

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