PHOTO CREDIT: Baby Steps Therapy
This Episode’s Guests
Mary Beth Crawford is a licensed physical therapist and DIRFloortime® Expert and Training Leader who founded Baby Steps Therapy in 2008, a DIR® clinic offering physical therapy, speech therapy and occupational therapy. 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, on her unique approach to pediatric physical therapy, and teaches for the International Council on Development and Learning (ICDL).
Returning guest, DIRFloortime® Expert and Training Leader Mahnaz Maqbool, is the speech-language pathologist at Baby Steps Therapy. She also teaches certificate courses for ICDL and has taught courses and mentored internationally including in Pakistan and Bulgaria. First-time guest, Suzanne Gabriele, is an occupational therapist and DIRFloortime® Advanced Practitioner who is dedicated to bringing awareness and celebration for all children’s unique individual profiles. She has provided in-service training and lectures on the importance of the synchrony of sensory, motor and socio-emotional development as it relates to occupational therapy and the DIRFloortime® approach.
Suzanne has advanced training in sensory integration and is certified in the Evaluation in Ayres Sensory Integration (EASI). Some of her other certifications include the Safe and Sound Protocol, Rhythmic Movement Training (RMT), Tactile Integration from the MNRI®, primitive reflex evaluation and integration, extensive training and collaboration on ocular motor differences and treatment, certified educator of infant massage, and Interactive Metronome (IM).
This Episode’s Topic
The therapy trio from Baby Steps Therapy, a DIR® clinic offering physical therapy, speech therapy and occupational therapy in the suburbs of Philadelphia, is here to discuss their collaborative Floortime approach used within their strengths-based studio to support growth within the Functional Emotional Developmental Capacities (FEDCs). Baby Steps embodies a true DIRFloortime® collaborative.
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How was Baby Steps Born?
Mary Beth says that when she started Baby Steps, the entire mission was to practice Floortime, syncing up sensory-affect-motor as the underpinning of motor development with the intention of, and thinking about, how critical other people are in bringing the approach to light. She knew she needed to work with people whom she valued and trusted and who challenged her thoughts and thought differently from her.
Mary Beth and Suzanne met working at A Total Approach with occupational therapist Maude Le Roux about twenty years ago. Then, about five years ago, Suzanne started her own business and her and Mary Beth decided to collaborate. Next, about three and a half years ago, Mahnaz joined. She explained that they not only provide Floortime together, but for each other as well, providing safety and co-regulating each other. It’s a complete model in how they support each other, Mahnaz says.
Mary Beth continues that part of being a true collaboration is to create enough space for regular discussion about all of their mutual cases and regular communication and relationships that each of them have with their clients, their families and with each other. They find that they can provide the most quality with their trio. They aim to maintain the integrity of what they do when they consider expanding the clinic. Mahnaz adds that their meetings are really key to why things work so well.
I asked if they consider this their reflective practice (as I’ve podcasted about before). Each of them provide mentorship and have reflective mentors outside of their collaboration, but they also consider their conversations with each other as reflective practice including the therapeutic use of self in providing the best Floortime to support their clients in the way it’s warranted in each situation, Mary Beth explains.
What Does a Session Look Like?
I asked Suzanne to describe a typical session. She said that they’ll evaluate a client in order to decide, based on each unique profile, what will work best for them and for the dynamic of the family. It’s great to have three professions to pick each other brains, she adds. Each session is Floortime whether it’s occupational, physical, or speech therapy. They’re holding in their minds the unique profile, what the client goals are, and the client’s Functional Emotional Developmental Capacities (FEDCs).
Mahnaz adds that they’ll often do co-treats as well where they can each bring their own lens into the session. It changes the dynamic in the room by taking the pressure off the child as they interact with each other to have the triangulation with the child. Mary Beth adds that they’ll discuss in advance how they’ll use the dynamic to benefit the child.
All three of them use the FEDCs to guide the therapy, Mary Beth continues. Whether it’s OT, SLP, or PT, it’s a Floortime approach. If a child is working in language or academics, they might have Mahnaz work with the client first. If it’s a child whose coordination and balance stands out, then that child might start in PT. If it’s an ocular motor piece, they might start in OT. They also consider which of their temperaments will match the family. It’s fluid and individualized to the profile of the individual and family.
Mahnaz adds that since they work so collaboratively, you will see movement in her SLP sessions and she’ll be thinking of ocular motor skills and gaze stability. Suzanne says that she wouldn’t have paid as much attention to the language before their collaboration. She’ll now support the language piece as well.
I commented that it does seem that they learned a lot from working at A Total Approach. Mary Beth says that they often talk about how much they learned from Maude. Suzanne adds that Maude laid the groundwork for the reflective process. Employees were videotaped all the time and just had to get used to it. She started there as a student, so it was a great place to begin her career.
What if I Brought My Child?
I put the trio on the spot and asked how it would look if I brought my son to their clinic knowing that his OT is working on dyspraxia and movements, that his SLP is working on really developing a story and staying with a story. Mary Beth says they’d first do an intake call and then in person meet with Suzanne and her together for a couple of hours, explaining how they want to first and foremost make my child feel safe before developing a program.
They would probably take turns interacting with him and talk about what he feels his strengths and challenges are, and explain what they do. They would want to harness the kinesthetic body sense and really support motor planning, learning, and development in any way that provides him agency and meaning with the focus being on the body.
Mary Beth adds that she recently taught her Affect-Mediated Motor Development course through ICDL for the second time and the entire six hours discusses the ways motor development can support affective and sensory development. They’d use their Floortime techniques: their affect, intent, and collaboration.
Suzanne says that on the initial visit, they’d focus on getting a comprehensive evaluation. Sometimes Mahnaz starts first with clients. It really depends on the goals and needs, then they formulate the safe space. Mary Beth says that they may want to harness motor sequencing as a big goal, and underpinning that would be his somatosensory system, the vestibular registration piece, how his occular motor is impacting his visual system taking in movement. They would be holding in mind the entirety of the individual profile.
Mahnaz adds that the language piece will mirror the body. If the body is dyspraxic, often the language is jumping from one idea to another, so she would hold that space to follow the client’s ideas through, and deepen them as well. Mary Beth adds that they might start with a co-treat, which they don’t always do. It’s very dependent on emotional-sensory overwhelm, or how much affect might be beneficial.
They try to support, scaffold, and stretch the rubber band a little bit in terms of body and language development, and how ever they can get that to happen, they will do. Mary Beth claims that they don’t always get it right, and there’s always room for the rupture and repair.
New Clients and Connections
I mentioned that they might have families coming in with very young children, too, right after a diagnosis and the child might be very uneasy about being there, so it’s important how they put safety first. Mahnaz adds that they also want it to feel safe for the parents as well, knowing and feeling that it’s a safe place where their child is loved, respected, and valued that they don’t always feel that in other settings. As Floortimers, they do see the beauty in each of their clients. They are strength-based. Baby Steps is a safe place for them, the clients, and the parents, she assures.
Mary Beth continues that they then want to figure out what brings out the joy with a new client. It’s so important how much fun they have, Mahnaz says, as she hides under a table playing hide-and-seek or plays pickle ball. Their joy is natural and real and the parents play with them. It’s a fun space.
Suzanne adds that an added piece is how organic it is that the parents end up meeting and forming friendships. Pre-pandemic they had more social opportunities and they do plan to get back to that because their families do enjoy meeting each other, Mary Beth says. I pointed out that parents can share experiences when their kids are the same age, and if there is an older child, parents can learn from that parent and their experiences.
Every child will vary in their FEDCs. I described the FEDC development in my own child and mentioned how Floortimers meet each child where they are developmentally. Mahnaz talked about working with some of their clients who have higher capacities. It made me think about something Dr. Gil Tippy said in a past podcast which he had discussed in the DIR 310 Functional Emotional Assessment Scale (FEAS) ICDL course that sometimes he comes in at a higher capacity to get engagement at FEDC 2 with older children who have the higher capacities.
It’s why it’s so important that we understand the FEDCs as “capacities” and that spiral that’s constantly dynamic, I stressed. It’s not about steps. Mary Beth says that they have a client whose imagination is the portal into his world. If they had started at FEDCs 1 to 4 it would have taken so much longer. They had constrictions in engagement outside of their immediate visual space, extension and postural control, head and body dissociation, gaze stability and ocular motor challenges. Putting safety first, they started in FEDC 5, 6, 7.
It reminded Mary Beth of the spiral that occupational therapists Gretchen Kamke and Amy Lewis used in their presentation on regulation at the 2024 DIR® conference in New York City about how when you’re moving through the capacities (FEDCs), you loop back and pick up the lower capacities on the way up and also how your capacity for regulation expands as you move through the capacities.
Challenges and Emotional Signalling
In terms of seeing two children together, it often happens organically, Suzanne says. Two kids will see each other and want to play together, or in the trio’s reflective practice they realize a client really needs one other peer in a co-regulated space to work on the higher capacities.
Mahnaz adds that co-treating really adds to the richness of the session. They come up with so many more naturally occurring challenges that are more realistic with emotional themes such as them having a race and one wins and one loses. It adds to the depth of the conversation thinking about some of the adolescents that they work with, even thinking about perspective taking. Did they understand you? Do they need more clarification.
Mary Beth says that it took each of them some time to understand each other. They often try to send affective signals to each other in some of these sessions with very verbal children who have constrictions in sending and receiving signals. Mary Beth says in the early years she’d be sending huge affective signals and only after a lot of communication with each other, they got to know each other much better.
Suzanne adds that they can now be so much more effective in the session, reading each other’s affective cues, adding in humour and problem-solving with the child about what Mary Beth is feeling, for instance. They are also using their genuine affect as Floortimers. There are layers of conversations they can have. When things get cooking, it’s really amazing, and it takes a lot of communicating and collaborating, Mary Beth concludes.
Reading Emotional Signals
In the previous episode, we discussed following the child’s emotional intent and before that I had a podcast with Brookes Barrack, also in a collaborative clinic in Kansas City, on gestural development. Both relate to this episode’s topic. I mentioned how perspective taking is developmental but once you are a bit older, I wonder about autistics being able to recognize emotional signals but maybe not acting on them like neurotypicals will.
Mary Beth says they focus on the way they use gestural communication, facial expression, and prosody to send and receive communication turns with the underpinning of FEDC 2, sharing joyful attention, and then opening and closing circles of communication preverbally in FEDC 3 for the purpose of communicating.
They do have a lot of adolescent self advocates they work with who come in with challenges sending or receiving emotional signals, while others understand it so in-depth and choose not to respond. They look at the sending and receiving of signals for the purpose of communicating versus intending to be in an interaction. One client expressed really wanting to be supportive of their friend, but not really knowing what to do with the emotional signals from their friend.
Suzanne says that one client uses a letterboard to communicate and doesn’t have a goal to work on other ways to communicate, so it’s not a goal for her. The client has other goals. They respect their clients’ wishes.
As developmental specialists, Mary Beth says, they want to create a space for the potential to develop these three areas (sensory-motor-affect) of sending and receiving communication turns. If dyspraxia is impacting someone’s capacity to gesture, and they really want to communicate with their bodies, Mary Beth says they will get thoughtful and supportive of this. Mahnaz adds that there are many clients who are very verbal where they do silent sessions working on affective, nonverbal communication to be able to send and pick up cues.
They want to provide access to everyone to have the agency to communicate how they wish. They’re always thinking about how each person’s differences will impact their capacity to engage, relate, communicate, and move their bodies in their intended way. When they are able to work in collaboration on this, it’s the most optimal, Mary Beth emphasizes.
Humans in relationship continue to expand. And that is the premise of how we work together.
Virtual Sessions
Suzanne explains that they do both virtual and in-person sessions, but what they always do is meet over Zoom with families to take the time to reflect on the sessions, review video, and share what they’re feeling. Suzanne says they’re often more valuable than the sessions themselves because they can stop and think about the progress, and be strength-based, reframing what they see.
Mahnaz adds that the Zooms allow them to explain what they’re doing in the sessions because it might be confusing why a speech therapist is playing pickle ball. They can unpack the sessions to make sure there’s a constant collaboration. And it’s about building trust, Mary Beth adds. It becomes a real feed-forward system when they reflect on the sessions.
I added that they are valuable to get follow-up at home, too, when they have tips of what they can do at home and the rationale.
This episode’s PRACTICE TIP:
Let’s look at where we are getting our information and routines from. Are we maximizing our opportunities to collaborate and take in different opinions?
For example: If we have only had one therapist’s opinion on our child’s progress, we might be missing out on other areas of growth we could be focusing on and researching, on our own (if we don’t have access to therapy).
Thank you to Mary Beth, Mahnaz, and Suzanne for sharing their collaborative DIRFloortime® practices used at Baby Steps Therapy. I hope that you learned something valuable and will share it on social media.
Until next time, here’s to choosing play and experiencing joy every day!
