A Floortime Approach to Fears and Phobias

by Affect Autism

This Week’s Guest

Dr. Karen Levine is a Developmental Psychologist and a Developmental, Individual differences, Relationship-based (DIR) Model Expert and Training Leader based in Maine. She has a private practice specializing in treating young children, both neurodivergent and neurotypical, with a focus on anxiety and phobias. She also has a part-time appointment as a lecturer in Psychiatry at Harvard Medical School. She will be teaching a course for the International Council on Development and Learning (ICDL) next month called TREATING FEARS AND PHOBIA IN YOUNG CHILDREN: An individualized, interactive, joyful, play-based approach on Sunday, June 11th, 2023 at 4pm Eastern.

Bonus Insights

Our Children’s Fears and Phobias

Every Monday, I facilitate ICDL’s parent support drop-in where parents ask questions that Dr. Levine has answers to, such as “My child had a bad experience with their tooth, and now won’t go to the dentist.” My own son had a medical tragedy at age 2 and has a fear of band aids. He is also terrified of vaccines. Once he gets the vaccine he’s fine. It’s the anticipation leading up to the vaccine that is so terrifying for him. Dr. Levine says that during Covid she did a lot of work around vaccines with anxious children and families.

There’s so much we can do around these events, Dr. Levine says, because it’s the mostly the emotional pain rather than the physical pain that causes the anxiety and fear. Of course, it can hurt and are uncomfortable, but children’s nervous systems can generally tolerate the discomfort about teeth brushing, band aids, or vaccines, she informs us. It’s the emotional piece, and that’s what affect is all about, she says. That’s where we can have such an impact with kids through play around their emotional frameworks. Dr. Levine will cover many examples in her course, including kids who are scared of hand dryers in public bathrooms, kids who have fears around different foods, and much more.

Her Early Career

I asked Dr. Levine how she got into this work. Before she became a psychologist, she said, she was a toddler daycare provider. She got to see a range of toddlers and this is the age where fears spring up. They’re just starting to play more symbolically and interact. She loved working on their fears and distresses through play. Many had separation anxiety about their parents dropping them off, so she would do lots of play around good-bye crying, “No! No! Don’t go!” as the child and the child playing the role of the parents.

Karen found that the children enjoyed it so much and it helped with their fears. Then, she became a psychologist, and after that, discovered Floortime. Her approach is very Floortime-adjacent. The adult has an agenda, but they center it around working on it through the child’s interests. Most interesting is that most children are also fascinated by the things they’re scared of, similar to how adults like horror movies, Dr. Levine explains.

When Dr. Levine began to do Floortime with autistic kids and kids with Williams Syndrome, an area she specializes in, she found that this approach was fun to do and successful in treating fears and phobias. Selfishly, she said, it’s also very satisfying as a therapist to see progress so quickly. Yesterday the child couldn’t go to a birthday party and tomorrow they are happy to go because they’re not scared of the Happy Birthday song anymore, etc. You can really make a difference, and you can help parents make that difference, Dr. Levine explains.

The Missing Page

I told Dr. Levine that I needed her 10 years ago when my child had such severe separation anxiety at nursery school drop off. As parents, we tend to walk on eggshells because we are just so scared of seeing our children melt down, and now Dr. Levine offers us this amazing alternative of doing exactly the opposite and facing that fear directly in a playful way so that it’s fun for everybody. It was super insightful that she instinctively knew how to help the child instead of distract them with their fears through playful interactions.

I shared how Dr. Gordon Neufeld talks about ‘immunizing’ the child to what they’re scared of by inviting the inevitable and talking about the fear. Dr. Levine responded that oftentimes in social stories, you’ll see that that page is left out: the one where the child is terrified. What happened to that page? She continues that sometimes the standard Cognitive Behavioural Therapy (CBT), that includes gradual exposure, is done in a similar way to what she does, but sometimes it’s done in a way that induces distress. She doesn’t think that’s the way to go and says it’s not necessary. If a child starts to get scared, you back away, add more playfulness and fun, and then proceed, she states.

Finding our Child’s Boundaries

I pointed out how Dr. Stanley Greenspan talked about using ‘frustration tolerance‘ to figure out where the child’s boundaries are by letting them set those boundaries when you add a bit of gentle frustration, then backing off when they indicate that it’s too much. As Floortimers, we instinctively do this, Dr. Levine says, and it’s called attunement. It doesn’t mean you never push the envelope, but you back up if it gets too realistic too quickly. Backing off and increasing the playfulness reduces the child’s anxiety, she explains. 

Dr. Gil Tippy calls it having your foot on the gas and brake at the same time. Karen thinks of two sliders where one is how realistic it is and the other is how playful and fun you’re making the experience. You can go up and down with both sliders. I shared how Occupational Therapist, Dr. Virginia Spielmann compared it to a soundboard with various levels and in looking at Individual differences, how you adjust each slider for each child. Dr. Levine agreed and said she does this in her work as well to figure out how you pace it, how loud you make it, and finding out what’s funny to each child.

Tapping into our Child’s Sense of Humour

Some children like loud and super funny, while others like more subtle humour so they don’t get overwhelmed. You really have to tailor the work to the child’s individual differences, Dr. Levine explains. Dr. Cindy Puccio did her dissertation on Humour and Floortime and she talks about humour as an Individual difference, Dr. Levine shares. When you’re using humour to treat fears and phobias, you don’t want to target it to their most complex level of humour they can access.

You want to use their favourite level of humour, she explains. If they like puns, you can use a lot of puns. If they like taboo humour, you can have a character jump into the trash can if that’s funny for them. Your goal isn’t to increase their Functional Emotional Developmental Capacities (FEDCs) in that moment. It’s to help them stay relaxed, and stay non-anxious, as you gradually incorporate the thing they’re afraid of, Dr. Levine explains.

Walking through an Example

Dr. Levine discussed a child with Williams Syndrome who had medical trauma who was scared to have their blood pressure taken but needed to have their blood pressure monitored regularly. She will show this video in the upcoming course if you want to see it. Even kids who haven’t had medical trauma are often scared of medical procedures, Dr. Levine explains. It’s physically intrusive, it’s unusual for a strange adult to intrude on your body in that way, everybody’s in a hurry, and people are stressed. The child was terrified and would always be in a total meltdown, so they couldn’t get an accurate reading of the blood pressure.

The child’s father was an Emergency Medical Technician (EMT) so they had the equipment at home, but you can buy empty syringes or borrow medical equipment from a doctor’s office, Dr. Levine suggests. The real equipment is another level of reality that if your child gets used to, will help when the actual event happens. The mother brought the blood pressure equipment that the child was scared of.

Dr. Levine likes to do this approach with the parent being involved, so she met with the mother and child. Sometimes the parent can just go ahead and do it and that’s great, but sometimes because parents have had so many intense experiences with the child around the fear, it helps to have a third person there who doesn’t have that history of anxiety around the event, Dr. Levine explains. She can manage the play and affect around it.

In a hotel room, Dr. Levine showed the child a doll and a toy blood pressure kit. She started at the level of reality that isn’t going to be scary to the child at all, but introduces the topic. She did the usual Floortime play and was playing around with fear and had her doll be afraid, then be OK, and saw how he responded. Then the child put the blood pressure cuff on Karen and she played with fear, saying with a lot of affect, “Don’t do it! I’m scared!” The child was fascinated and leaned in and looked right at her and said, “Again!

He wanted to see what that fear felt like. People have asked her if this is teasing the child. She says it is not. The children get the message, “Is this what fear is for you? Is this what it’s like?” Karen explains. He related and is wondering if this is the feeling that he has. He said, “It’s ok, it’s ok,” repeating what he’s heard from others during his own experiences of fear. Next, he got interested in the dial that goes around for the blood pressure on the toy one. They looked at it going fast and slow.

Next, Karen brought out the real blood pressure cuff and he was interested in the dial on it, without being scared. Then she put it on her arm and he was ok with that as well. Karen thought he might be ready, so she suggested the mother try putting it on him, but he got scared. So, they upped the fun and brought the reality down a bit. She realized she hadn’t yet incorporated the feeling of the cuff on his skin. Next, she put it on his shoes to check his shoe’s blood pressure and he thought that was funny. She told him to say, “No!” and when he did, she would throw it away, and he thought that was funny.

Then she put it on his knee to check his knee’s blood pressure and they played similarly, and slowly, she worked up his body as he enjoyed yelling, “No!” As she kept getting closer to his arm, he was starting to get bored with the same “No!” game and got interested in the squeezy bulb, so Dr. Levine showed that to him and was able to put it on his arm and said, “No!” Then he let her squeeze it on his arm and let his mother squeeze it on his arm twice as he was dancing and happy. This happened in just a few hours, she explained.

The Results

Sometimes the phobia can be gone in one or two sessions that are long enough, for kids who can stay engaged, Dr. Levine explains, and spreading it out over many sessions works better for other children. I commented that just taking that time to prepare the child by letting them get used to the procedure is something we never do! It’s brand new to them and they don’t know what to expect! Dr. Levine says that kids who are able to co-regulate, or aren’t prone to anxiety anyway and are able to use a lot of language to co-regulate, can get through these things without such difficulty, but when you have trouble with communication to the point where it’s not enough to help you co-regulate, or if you have trouble picking up on the cues in your environment to feel safe, it is tough.

People often ask if it generalizes. Sometimes it does, Dr. Levine says, but sometimes you have to do a ‘booster shot’ of that kind of play. Sometimes the child’s baseline anxiety is up on that day so you see the anxiety again, but once you’ve done this once, you can often do it again much more quickly. Dr. Levine said letting the child play with the equipment and letting them feel like they’re in charge, instead of feeling like the scared victim, is just terrific. A shared humorous state can override the mild discomfort, Dr. Levine says.

Dr. Levine gave an example from a video that went viral of a haircut of a boy who had both Downs Syndrome and sensory issues. The hairdresser instructed him to yell, “Stop!” when he wanted him to stop, so they had fun playing around that with the hairdresser stopping on the spot in a funny manner. It’s more of an emotional discomfort, Dr. Levine continued, which is often harder for the children to manage than the physical discomfort, and as Karen mentioned earlier, the child picks up on the parent’s anxiety as well. Playing with the fear is the unspoken issue because the parent doesn’t want the child to be afraid, so getting it out in the open makes it less scary for both the parents and the kids!

The Research

There’s lots of research on Cognitive Behaviour Therapy (CBT) on treating phobias with gradual exposure and with children as well, but there’s almost none on humour in children, and especially not on anxiety and children OR adults and treating it in this way, with a lot of humour, Dr. Levine says. She was presenting at a conference once about her work with children with Williams Syndrome and met Dr. Bonnie Klein-Tasman, who is an anxiety treatment researcher specializing in Williams Syndrome at the University of Wisconsin-Milwaukee and suggested getting a grant from the Williams Syndrome Association, a mostly parent-organized association.

Parents wanted research on how to treat their children’s anxiety. It was a dream to have an approach and have a research team study it, and turn it into an evidence base like with Floortime, Dr. Levine shared. During Covid, they had to stop seeing children, but they started a website which is almost done and will be launched soon that describes the approach. They wrote up a paper about the patients they had done this with during the Pandemic and it is published. It was mostly to manualize it and document how it was done, but they were happily surprised to see how much progress the children made. One boy came in terrified of vacuum cleaners and by the third day, he was vacuuming the entire hall with great joy. The same thing happened with a child who was scared of hand dryers. Not everyone made that much progress, but many children did, she shared.

What to Expect from the Upcoming Course

The ICDL course on June 11th, 2023 entitled TREATING FEARS AND PHOBIA IN YOUNG CHILDREN: An individualized, interactive, joyful, play-based approach, will be similar to this podcast, but will go into much more depth in each component with video examples and cover specific phobias as well. Dr. Levine will talk about her thinking about why neurodivergent kids are more prone to having more phobias in terms of having less ways to easily access natural co-regulation, and if there’s time at the end, she’ll also do a Question and Answer period. Following the course, Dr. Levine will also be our guest at ICDL’s weekly parent support meeting on Monday, July 10th, 2023 where we’ll have a post-course Q & A for parents who attended the course.

Working with Dr. Levine

Each child is different, as we know, and so the exact approach is going to vary for each child. The principles are the same, but you can’t prescribe, just like in Floortime. It’s very individualized, Dr. Levine stresses. How scared a child is with each aspect of pretend also weighs in to the approach. Dr. Levine always asks parents to let her know their child’s cues because parents know their child’s ‘tell’ the best. She is all virtual on Zoom, and most of her patients are in Massachusetts where she used to live. She has a lot of props and uses YouTube a lot, looking at videos together with no volume, then a little bit of volume, etc. for things like children who are scared of thunderstorms, for instance.

In some ways, Dr. Levine explains, Zoom works well because the parent is home with the child in their comfortable environment and it allows the child to learn how to do this with their child. Sometimes one parent or a relative is better doing this approach than the other parent. Sometimes parents don’t play with their children in this way. She suggests finding the person who naturally does this kind of play with the child, and sometimes the parents are interested and want to learn. Also, what adults find funny or acceptable varies from person-to-person, culture-to-culture, or subculture-to-subculture. It’s important to really explore what the parents and child both think is funny, she insists.

Dr. Levine will first ask the parent what their child thinks is funny and tell them how she’s done it with different kids to see if parents think their child would respond to that. She would also have the parents send her videos of them playing with their child so she can get a feel for the child. She’ll try out different play scenarios. Often, parents who have done play scenarios haven’t added the, “Ouch! Ouch!” fear aspects, if it’s around getting a vaccine, for instance. Dr. Levine has videos of her getting her vaccines to watch. Sometimes the kids won’t want to see it but will peek. She will also show it to them backwards, which is funny as you watch the needle come out of the arm.

One child she worked with was still resistant to getting a vaccine after doing all of that kind of preparation, but had an interest in animals, so Dr. Levine found a video of a vet giving horses vaccines. She also found instructional videos of how to vaccinate your own dogs. Then they gave an orange syringe shots with coloured water.

When you think about unbundling the components, Dr. Levine explains, you have the entire shot scenario, but there’s also the whole sensory piece. You can use syringes to drop water on each other’s arms to give closer approximations to the actual experience, she says. The child in her example didn’t want to do that, but would drink sugary water through the syringe, which is a good step forward. Then between sessions, she would get parent feedback and suggest different directions. 


Sometimes parents feel silly doing that pretend, “Ouch!“, but enacting the fear validates the child’s experience, Dr. Levine explains. If it’s around brushing teeth or going to the dentist, Karen suggests closing your mouth and saying, “No you can’t get in here…” (through mostly closed lips) “…I’m going to hit the ceiling!” making it clear that you’re playfully pretending the child’s feelings. You can fold your arms over your mouth or put a mug to cover your mouth saying, “I’m not letting you in there!

I shared how my son will say that he wants to throw the people in the forest when he doesn’t want to go to school and Karen says that he is trying to describe how big his feelings are about it, so how you play with that will depend on what it evokes in the child and what they understand is clearly playful and unrealistic. She had a client who had separation anxiety so when the mother went to walk around the block and the child asked where her mother was, Dr. Levine said, “She went to the moon” and the child laughed and said how the mother was just walking around the block. If you can get the child giggling, that’s great.

Manageable Doses

It’s really a trial and error process, says Dr. Levine. Bring the fear out in manageable doses, make it fun, and this shifts the child’s feelings about it, she offers. For example, with hair washing, you can just wash one strand of hair to get started. Sometimes kids can be scared of the bath so you want to separate hair washing from the bath. Sometimes parents will say, “Oh, I’ve tried that already” but you need to be willing to try it a bit of a different way and be flexible without giving up. 

This week’s PRACTICE TIP:

This week let’s try to face a fear of our child’s head on with humour.

For example: If your child displays an anxious response to something, think about approaching it in play with a puppet or figure while they’re in the bath, for example, or in their play area. Have the figure protest the fear with affect like Dr. Levine demonstrated and see where it leads.

Thank you to Dr. Levine for sharing her approach to phobias and fears in children by using humour and play. 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.

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

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