Physical Therapy is Enhanced Using a Floortime Lens

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 expand on how Physical Therapy is enhanced using a Floortime lens.

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. Again, as said in Part 1 a few months back, her lofty goal is to bring the Floortime approach to more developmental pediatric Physical Therapists. In Physical Therapy (PT) they focus on affect, sensory, and motor. All of these synchronously develop together to optimize a child’s motor development, Mary Beth states.

Joy in Movement

Movement often brings joy to children. Mary Beth thinks about movement and Physical Therapy. The joy in a shared world where a child and adult are regulated and connected is foundational, Mary Beth emphasizes. Often we see adults come in and try to control a child’s environment by having them sit down and be sedentary, she says. If a child is seeking movement, let’s bring it in! 

Research on Mirror Neurons

In our last Floortime and Physical Therapy podcast, we hit on Dr. Greenspan‘s concept of the foundation for the DIR/Floortime approach of bringing three pathways together: our motor, our sensory, and our affectual-emotional pathways. What we didn’t talk about, Mary Beth offers, is the newer research in mirror neurons which looks at the mirror neurons in our motor cortex having a relationship with the understanding motor patterns and learning motor patterns, as well as the intent and where that affect of the observer is. Triggering their mirror neurons is linked to lower brainstem levels where intent is being encoded. If we really think about that piece, Mary Beth postulates, it’s synchronous to Dr. Greenspan’s theory in the sense of how our motor and our emotional intent bring together that body awareness piece.

We know from research that kids who have regulatory challenges or who are diagnosed on the spectrum or identify as autistic have decreased mirror neuron activity, Mary Beth says. One of the things she wants to emphasize as part of the foundational capacities in Floortime and Physical Therapy is that there’s a lot of research in the Physical Therapy world about how the vestibulo-ocular reflex (VOR) and gaze stability vestibular rehab exercises can support gaze and that that gaze stability, in turn, has the capacity to support mirror neuron activity.

VOR and Gaze Stability

The vestibulo-ocular reflex (VOR) is a reflex of our vestibular system, Mary Beth explains, which is in our inner ear mechanism which includes semi-circular canals that detect rotary movements and gravitational, body/head-in-space awareness. It’s one of our major senses, she says. It’s an integrator of all of our senses. It has ascending and descending tracks, connected with our arousal, emotional regulation, and our eye muscles. So the VOR is a reflex that develops. It’s not a primitive reflex that gets integrated. It’s a different type of reflex that stabilizes our gaze as we move through space.

What the research shows now, Mary Beth says, is that kids who have regulatory challenges and/or kids who might be relatively shifted into hyperarousal (fight/flight), have more challenges with their gaze stability. If we think about that, Mary Beth suggests, marrying that with some vestibular rehab might really support the child’s capacity to take in that nonverbal/preverbal emotional cueing, which we know–as Floortimers–is so foundational to all of the higher capacities, especially in the fourth capacity where we start to use our preverbal communication and some words might start to come in.

Synchronizing that emotional signalling in a shared world is the foundation for developing motor sequencing and developing the capacity to hold on to our ideas while we’re processing the ideas of our play partner, and while we’re navigating emotional reactivity associated with some boundaries, all while maintaining our regulation while we’re negotiating the play partner in capacity four, Mary Beth says. All of this requires a lot, and one of the foundations is having the gaze stability and that intact vestibulo-ocular reflex (VOR), which supports this process.

VOR Rehab Exercises to Support Gaze Stability

Mary Beth says there are VOR rehab exercises such as holding your finger in front of your face and turning your head left to right while keeping your gaze on that finger. In many of our kids prone to hyperarousal, the eyes and the head move together. This means that when you’re moving in space it leads to a couple of things, Mary Beth explains. First, you might have an under responsiveness to the vestibular system. These kids need a lot of movement. So, one of the first things is, she continues, to provide a lot of opportunities for movement because that’s what’s going to harness that connection and that relationship, which is a critical piece to expand into our higher capacities. So, join in the movement, she says!

This is where it gets tricky, Mary Beth suggests, because a Physical Therapist might say to do 50 repetitions of a gaze stability movement, which works if two people are having fun in a shared world and it’s not triggering a stress response. With our kids, to work on the VOR, we might want to come in and tailor the environment, as a Floortimer, to set up some swing activities or some bean bag games where there’s a lot of crossing the midline, and tracking activities with blocks. 

Mary Beth shared a video at the recent ICDL conference, where she presented on this topic, of a little guy in a swing where he was well supported and getting a lot of movement. She set up blocks on either side and he was able to turn around and have a great time tossing the blocks off the swing and not knowing that at the same time he was really working on his gaze stability with this really fun activity.

Gaze Stability and Emotional Signalling

I asked Mary Beth if gaze stability improves with practice. She believes that it does, but there isn’t a lot in the literature on VOR rehab on kids with regulatory challenges or autism diagnoses. There is a lot of research on gaze stability being improved with vestibular injury, concussion rehab, and central nervous system challenges that includes working on the gaze stability and the ocular motor musculature because the muscles around the eyes can be strengthened. 

Over time, these exercises can be supportive of the emotional signalling piece and having an improved gaze. It’s an area that needs more research for our kids, but from Mary Beth’s clinical observations, working on gaze stability and being cognizant of supporting that, while supporting foundational capacities, can support that ability to emotionally signal, and develop the theory of mind piece, in terms of understanding our own selves, our own bodies and motor planning, and then being able to understand our play partner’s.

The Use of Affect

I wanted to emphasize a couple of things Mary Beth said. Often we bring our kids to appointments and tell them to do something and they don’t want to do it. That’s why in Floortime, we make it fun to do. That’s supporting the early capacities of regulation, engagement, and circles of communication. If they get distressed, they’re not having fun. So, like Occupational Therapist Keith Landherr shared with us, you don’t just put a kid in a swing; you interact with them and make it fun, which supports those early capacities.

Mary Beth also talked about emotional signalling, which is one of the key components of Dr. Greenspan’s theory. Gene Christian and I did a podcast about preverbal affective signalling that gave Mary Beth words to what she believed, and now, she says, we have science to support it with the mirror neurons research that supports that brilliant hunch that Dr. Greenspan had. In his books, Mary Beth says, he talks about how somehow there was a disconnect of the emotional intent, and meaning fell off the motor pathways. They weren’t synchronously developing together. 

Dr. Greenspan believed, and Floortimers believe, too, that with the right approach, and with our attuning and supporting these individual differences of our play partners, that that intent can meet the praxis piece. This was his Affect Diathesis Hypothesis, I added, which was my first ever blog post and why this site is called Affect Autism. Unless you can understand what’s going on in yourself and your intent, it’s very difficult to understand that in someone else, Mary Beth asserts.

Theory of Mind

As an aside, when Dr. Simon Baron-Cohen said that autistics don’t have theory of mind, it was very controversial and many autistic self-advocates said that was not true and in fact it’s the neurotypicals who often don’t show theory of mind in understanding the autistic experience–which I totally agree with. What Mary Beth and I talk about here is that this process–regardless if you’re autistic or not–is developmental, as I discussed with Occupational Therapist Maude Le Roux in another podcast. If our children are not understanding in their own body what they are feeling, and their intent, they will be delayed in developing theory of mind compared with others who are typically developing.

I shared how my son is almost 14 and will interrupt me when I’m talking to him with something completely unrelated, and is not expressing that he understands when I am angry or grumpy unless I explicity use affect, and state that I am feeling angry. He loves that affect piece when I do express it and he’ll ask, “Are you angry, Mama? Be angry!” and then enjoys me expressing that I am angry. Mary Beth said that we need to stay there with a child in that emotion. You have to feel and experience anger to know what it is. You can’t teach it. It has to be mirrored to us by our co-regulator, Mary Beth states.

Co-Regulating

For kids to really experience what’s going on, as the co-regulator in Floortime, what we want to do is match to a degree–not in a scary way that triggers fight-flight–their intense emotion. We don’t want to say, “There, there…it’s ok“. That is confusing for a child who is feeling overwhelmed by their emotions. We want to genuinely match the affect with, “Arg! You’re feeling so scared!” without telling them how they are feeling, and then say, “and that’s ok” and co-regulate. We don’t want to co-regulate before we match it, Mary Beth suggests. She says we might also want to match it and say, “I’m scared!” so the child can start to understand through our mirroring what’s going on with their feelings. Then we co-regulate.

If the child’s gaze isn’t stable, Mary Beth says, they’re not really taking in our emotional signalling in the non-verbal sense, so it might be confusing for them, and perpetuate this challenge with feeling and experiencing because they’re not really hitting those mirror neurons enough when we’re mirroring. They might need us to hold the facial expressions for a lot longer, and use more exaggerated affect as they’re developing this, because their mirror neurons are firing, but it’s at a lower amplitude in the firing. Let’s stay in this experience, Mary Beth suggests, and provide the movement piece needed to get there, and let’s harness all the pathways together.

We do presume the highest competence, Mary Beth asserts, and we do listen to self-advocates who have tremendous empathy and say that they shut down because they are feeling too much and need to take some time to process it all. I added that when I do hold a negative emotion, my son will sometimes get agitated and wants me to be happy and says, “Be happy, Mama!” Mary Beth said that he’s potentially not comfortable with his own anger. You can then punch a pillow or scream outside. If he’s really there with me, this shows him the process of then feeling, “Ahhh, I feel better.“

Let’s bring the motor piece back

 He is starting to label his feelings, though, and he’ll now say, “I’m getting angry, Mama! I want to hit you” so I’ll say, “Arrrrg! We can go hit a pillow or stomp our feet!” as I’m aggressively stomping my feet to show him. That is where motor, sensory and affect meet, Mary Beth says, where you bring in the movement piece to express your emotion. It helps the child make the connections. It’s hard for all of us to process our emotions without movement. There are motor patterns wired for all of us to express our emotions. It helps our kids feel and experience the emotions when we bring in the movement. 

My son is starting to use affect in his voice and on his face when he expresses his anger, along with using motor expression of slamming his fists down, or sometimes throwing or breaking things. I will say to him that it’s ok to feel angry, but it’s not ok to break things and then demonstrate how to punch a pillow or stomp his feet, so I wanted to emphasize that Mary Beth said to demonstrate the motor movement for them. Also, though, when my son is excited he will flap his arms vigorously which is a motor expression of his positive emotion.

I also wanted to point out the confusion when we talk about Floortime being joyful and what we’re saying about negative emotions. When we look at the Basic Chart of the Functional Emotional Developmental Capacities (FEDCs),–acknowledging that we are all managing our capacities all day long as we move back and forth from being dysregulated when we get cut off in traffic, for instance, to being regulated and functioning in our higher capacities–we want to know if our children can maintain connection when they’re distressed. Many parents say their kids meltdown when distressed and they can no longer maintain engagement or a back-and-forth interaction.

When we talk about shared joy and making it playful, I wanted to stress that we aren’t trying to suppress negative emotions. I think that sometimes confuses people who think it always has to be fun and happy. As Dr. Gil Tippy says, Floortime isn’t always joyful. We have to work through the negative emotions, but as I discussed with Dr. Gordon Neufeld a few podcasts ago, bring it into a playful realm. When you can bring it into the mode of play, it can make it less distressing. Mary Beth says this speaks to the newer science of motor learning in physical therapy and what parts of the brains are activated in the phases of motor learning. 

There are strong links between our vestibular and limbic systems, she states. Being engaged and sustaining that attention is part of the novel motor piece. If we’re experiencing those big emotions, we’re probably not learning a novel task. Choosing play is more foundational to novel motor learning experiences, however adaptation of our motor learning and planning, or the generalization of our new skills, doesn’t come until we have experienced the full wide range of emotions with these novel motor plans, Mary Beth explains.

Higher order capacities

Moving from FEDC 3 where you have joyful reciprocity to being able to handle boundaries in FEDC 4, and the reality principle that Dr. Greenspan talked about, is moving towards the symbolic. The only way around FEDC 4 is through it, Mary Beth says. You have to experience–and feel, Dr. Neufeld would say–a wide range of emotions when all these things come up, and feel validated for those emotions. You have to experience the capacity to feel regulated first in co-regulation, then in self regulation. That is the way to go from FEDC 4 into that symbolic thinking realm in FEDC 5, Mary Beth explains.

Expressing “I’m angry” has a symbolic meaning because you are using words as symbols (as long as you are not just repeating by memory without experiencing the feeling). You are sustaining affect, co-regulation, and the interaction to create the higher level thinking capacities, Mary Beth asserts. I mentioned that early on in Affect Autism I did a series of blogs of stumbling blocks. Dr. Greenspan really gave us tools of how to strengthen the capacities. Every single one said to strengthen the previous capacity to get better at the subsequent one. Each capacity will be so much more robust when the earlier capacities are strengthened.

The capacity to develop novel motor learning requires an awareness of the new task, Mary Beth says. That’s why in Floortime we talk about regulation and co-regulation. We can access those higher brain centers much more readily when we’re regulated. We can learn the new novel task. Once that motor plan becomes automatic, then less cognitive resources are required as we use implicit knowledge.

Sleep

What’s interesting with the vestibular rehab and eye movement activity is that we know that motor learning and sensory processing continues while we’re sleeping, Mary Beth says, and that sleep is an important aspect of the consolidation and retention phase of motor learning. It makes Mary Beth wonder about kids who struggle to fall sleep or stay asleep and struggle to keep motor plans they’ve learned over time. A big part of sleep is the phases of sleep including rapid eye movement (REM). Mary Beth wonders how robust the eye movements are during sleep for a child who doesn’t register vestibular movement when they’re awake. 

As an aside, Occupational Therapist Maude Le Roux and I talked about developmental growth spurts and how when you’re synthesizing new learning, our other skills might temporarily be lost.

Reflection

Autistic self-advocate Mickey Rowe mentioned in the last podcast that because he needed lots of vestibular input when he was younger, he loved walking on stilts and how going to the theatre he was able to witness rich, emotional interactions that helped him develop his own capacity to act. When we’re able to process emotions at a bit of distance with stuffed animals, too, in play, Mary Beth says. Processing the gamut of our emotions in FEDC 4, she says, is giving space to process those emotions. Whether it’s ‘up high’ space (i.e., upregulated), ‘no response’ space, or ‘the distance’ space in play, and not internalizing it, can all be great for emotional processing, Mary Beth says.

Because he didn’t speak, Mickey also said that people talked to him like he was a baby, but at the theatre, people spoke to him the same as they did to other people. We still want to interact in a natural way with our clients in Floortime, especially when children aren’t toddlers anymore. Mary Beth says that we all would benefit from Improv classes. Also, she says that the more we reflect on our own practice, the better we get at it. We don’t always get it right. It’s a constant process of giving it your best shot then reflecting. We all benefit from reflective practice.

Floortime Helps you Meet your Physical Therapy Goals

Mary Beth wants all pediatric Physical Therapists to know that using the DIR/Floortime approach is the way for you to meet your goals such as bike riding, stair climbing, etc. Understand the ‘I‘ (Individual differences) of your clients and use the tenets of DIR/Floortime. When you attune to yourself, you attune to the child and create a Relationship with the client and the family, and truly join the child in their interest. These are the ways to meet your goals through Physical Therapy including the bilateral integration and jumping jacks. 

Science has fully backed the notion that newer models for motor learning include affect states. No affective states were involved in understanding the science of motor learning when Mary Beth went to school, but now there’s a new model: Optimizing the Performance Through Intrinsic Motivation and Attention for Learning, or the OPTIMAL theory combines social, cognitive, affective, and motor behaviour, which Floortimers understand. We now have research now on the importance of incorporating affective states when you’re learning new motor tasks!

The science of motor learning really does support using a Floortime approach to Physical Therapy, meaning being aware of and validating affective states–not discounting or ignoring them–especially when it’s difficult, Mary Beth says. It’s really important to perseverance, even though it might involve more tantrums, more self-awareness and more co-regulation. Staying with those feelings and those challenges will get us into those bilateral tasks that are challenging, Mary Beth encourages.

Mary Beth continues that there’s so much research now that shows that coordinating the two sides of the body really coordinates the two sides of the brain to activate learning memory and other higher brain processes including linking bilateral integration in the body, supporting visualization in space, and developing and linking logical bridges in higher capacities. When the body is crossing the midline and doing these higher level coordination tasks, science shows that it supports the higher level cognitive skills that teachers and parents are looking for.

Mary Beth believes that it is the responsibility of all the pediatric Physical Therapists to be aware that these are skills that are foundational for all the foundational capacities–not just for the motor track. It’s about the affective, sensory, and motor pieces all working all together, she says. Mary Beth likes the analogy of trying a Calculus challenge if you can’t add or subtract. You need all three systems working together. 

Mirror neuron research has shown that in the premotor cortex of the brain, the same area lights up when we’re doing or watching someone do a motor activity. So, when we are modelling and making things look fun and showing things in a fun way, we’re also working on connecting the awareness of our motor task with what our intention is. We need to go back to our building blocks. Jumping jacks might be challenging for a child, so developmentally you might go down in your demands on the gross motor skills.

Summary

Mary Beth emphasizes that in Floortime, we understand all behaviours as communication and respect someone’s agency in communicating with their body or their words. When they are ready, making things fun like Freeze Dance, Simon Says, and other games, makes those higher level bilateral activities instrinsically more fun, she says. Every child is so different, so understanding each individual difference and how to attune to, and be curious about, each child you have the honour of playing with will have a profound impact of a Physical Therapist’s awareness of their own practice and their outcome. Creating those ‘just-right’ interactions is what we’re doing as Floortimers.

Thank you to Mary Beth for elaborating in more detail how Physical Therapy is enhanced by using a DIR/Floortime lens and approach 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!