Leaning Into Presence and Uncertainty in Supporting Development

PHOTO CREDIT: Pixabay

On Episode 313…

Occupational Therapist and DIR-Expert Maude Le Roux and homeschooling parent Daniela Bishop discuss the importance of clinical reasoning in attuning to the child by being present, staying in the moment, sitting in discomfort and uncertainty and making inferences about the child’s internal experience in order to have an essential starting point for developmental work.

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This Episode’s Guests

Daniela Bishop is a parent who thinks and writes about her experiences raising and homeschooling an autistic child with a complex developmental profile. She has a law degree and is a Registered Nurse in the Greater Toronto area in Canada. Her interest is in examining the real costs of dependency and care in contemporary social systems. She is slowly building her thinking out loud in her substack Revolutions In Care.

The Impetus for this Discussion

To quote Daniela in one of her substack articles, Relationship “is the medium through which adaptation becomes possible.” In another, she wrote, “Intervention within DIR was therefore never meant to be corrective or rehabilitative. It was meant to support the developmental process, not fix a child.” Daniela believes that many therapies are lacking the clinical reasoning to understand complex developmental profiles like her son’s.

Daniela’s 7-year-old son was diagnosed about five years ago and in the last three years, she has slowly come to the decision to stop direct intervention and embrace an indirect intervention approach through parent coaching and doing her own research and reading. She has found an occupational therapist in the last few months that she’s now working with. It’s a partnership without the hierarchy of the clinician being the holder of knowledge and expertise. It’s an involved partnership, Daniela says, and this is a key aspect of successful intervention, in her experience, as a parent and as a nurse.

It Starts with the Relationship

The idea of relationship resonated with Daniela upon reading Daniel Stern and Ed Tronick about how the relationship begins from the moment of birth. Joint attention is typically talked about as a dyad of parent and child, but in Daniela’s reality, it’s a triangle where the parent is holding the third element which is the space that we are holding between the child and parent. It falls on the parent to hold the space of what happens in the interaction when the child struggles with joint attention.

It’s the attunement component. The concept of clinical reasoning started to click after Daniela presented at ICDL’s DIRFloortime conference in 2024 when she was asked, “Do you feel like a clinician or a parent?” Daniela is a parent, but you’re always thinking on your feet with a child who has a complex profile. Occupational Therapy was highlighted for Daniela in Marti Smith’s book, The Connected Therapist with the description of task analysis.

Maude echoed the relationship being the pivotal piece that anchors the child’s existence and that when you look at the person’s profile–the individual differences, these pieces, including praxis, inform clinical understanding that brings forward critical thinking of what the task entails and whether or not there is demand avoidance around it. 

Maude encouraged Daniela to look at Iacoboni’s book on empathy that compiles scientific literature to look at co-regulation that sets up the circuit for empathy which forms the basis for having space for and understanding each other in a relationship. Empathy starts at the beginning of life through attunement, Maude says.

Nature Through Nurture

When people talk about nature versus nurture, Maude says, it’s nature through nurture. How does the environment and caregiver receive an individual’s temperament? Our temperament creates in us a need to be responded to in a certain way so that our temperament can then be molded into a personality which leads to the sense of self, Maude explains. Greenspan came from a psychodynamic flavour to explore the functional emotional developmental capacities (FEDCs). The individual differences of each clinical profile–each child and each parent–is what is linked together to bring out the highest potential, Maude says.

We’re also born with intelligence, she continues, but how it develops depends on how we are experiencing the world. If your world is safe, your intelligence can soar. If it’s hampered by postpartum depression where the parent can’t be as available, the child will adapt their intelligence in a way that’s protective. When we look at praxis and how we adapt our motor and sensory system to this world, Maude poses, we need to consider where the emotional connection is to the world that’s driving one’s sensory and motor to explore the things one needs to explore, to be open versus protective and defensive, and to be curious and explorative. This is where everything lands, Maude concludes.

We are a being inside of us, Maude continues, and this is what mattered to Greenspan. In the spiral of FEDCs, there’s a little sense of self that’s budding into autonomy. The more you go through the FEDCs, the more you are exposed to, “Can I understand myself better and understand what the world is asking of me so I can respond in an adaptive way?” and each response made and experienced is going to build the person, not just the FEDCs, Maude explains. The relationship is key to build that in an individual.

And in impacting that individual’s developmental process, I added that I think of remediation as the intervention. With my child’s disabilities, I want to consider what we can do to intervene to promote that developmental process (along with accommodations to support his growth). Occupational Therapy (OT) is key for me, and even Speech-Language Pathologist Brookes Barrack said that, in the beginning, if there are praxis challenges, she will refer families to OT first. 

Presence

Daniela appreciates Maude saying that it’s not nature versus nurture. It’s not an “either-or.” The conversation today too frequently revolves around camps of “either-or” with little room to meet, she says. The more she learns, the more she comes to believe that as long as we stay in relationship, we can solve any problem, and she sees that part missing in today’s therapies.

The DNA strand came to Daniela’s mind. It’s a dynamic system. And since she saw occupational therapist Gretchen Kamke present about the Gilfoyle spiral, she can’t unsee development as anything but in that way. It can spiral out very far if you have the right conditions or it can be a tight spiral if you have constrictions around it.

The process of development starts with being with which is about presence, Daniela states. It’s the attunement that shapes the presence. It can be quiet, intense, loud, etc. Daniela’s son needs intensity and she is intense and that works with him. He needs a bump in arousal to become engaged, usually through sensory-motor play and this started with Daniela examining her own presence to create conditions to support engaging and relating at FEDC 2.

This brings Daniela to the idea of contingency: presence that is regulating, that sustains engagement, and is contingent on the needs of another. That is the beauty of occupational therapy giving the gift of task analysis, she says. In thinking about what Daniela has learned from Developmental Fx, the SpIRiT Model, and the S.T.E.P.P.S.I. framework, she says that when you break things down–sensation, task, predictability–it allows you to understand physical presence and the psychological and emotional presence that is required to help shape the needs of the person in front of you.

Presence is an essential part of every relationship, Maude responds. We want to “get” each other. I get you and you get me, and because we are tuning into each other, there’s a natural affiliation of minds that brings forward taking the risk of learning, Maude says. This is an art that goes beyond the use of self. 

Applying the Art of Presence

Even in OT school, Maude was trained on the use of self, but they were also trained on task analysis with goals and objectives. Maude is grateful for that training, using it every day of her life, but the one part that’s missing in that is when you go into the session, to go with Greenspan’s words, she asks, “Whose agenda is at work?” When Maude goes into a session, she knows she wants to work on bilateral integration and get those two sides of the body to work together, but there is a child who comes in with a backpack of what happened prior to entering the door.

That’s the child’s nervous system’s state, Maude says. If that state doesn’t meet with her curious state about his sensorimotor system, then you can’t expect the child to make the switch to the therapist’s agenda just because they’re in that space. It’s so important when the child enters that space to see how ready and available the child is, Maude insists. If they’re not available, she’ll let the child explore the room while she talks to the parent while watching where the child goes out of the corner of her eye.

When the child settles, she joins them to create the joint attention with where their attention is at. That is the art of presence, Maude says–that she can flexibly manipulate her system to meet the child’s, because expecting them to meet hers is unfortunate. When you meet and the child feels that match, the child warms up. Maude follows their lead and she keeps in the back of her mind to bring that activity towards bilateral integration or the visual-spatial work as an OT. Never put your task at the cost of the child, Maude cautions. If you call the child “demand avoidant,” you need to look at yourself.

“I get you and you get me and together we’ll occupy these moments we have” is presence, Maude says. Her training didn’t give her that. She had to learn that.

Supporting the Human Being

Daniela says that society has trained us to be so concrete. She quotes Gretchen Kamke who asks, “Safety in service of what?” We’re doing things but behind the things we do there’s always a reason. In training to be an ESL teacher in Brazil, Daniela learned an important lesson. What do you do when you have a lesson plan and the lesson isn’t landing? You teach to the student, not the plan. You support the child, not your treatment plan. Daniela was taught that the therapeutic use of self is in service of the treatment plan, but it needs to be the other way around, she says. 

We are always working in service of development, in service of the child, and of the family system, she stresses. There are so many demands, which is not on the providers, but due to the containers that hold us: billing systems, insurance companies, college regulations, treatment plans, legal liability. There are all these conditions around us that constrain our ability to understand that the therapeutic use of self is not in service of the goals of the intervention but of development, Daniela repeats. This was the shift in Maude’s career and was her shift as a nurse.

Clinical Reasoning

Clinical reasoning is essential to supporting the developmental process, Daniela states. You may spend an hour preparing a session, but the child may not be available for your session plan. Then, you can use clinical reasoning to think on your feet with your implicit knowledge, and see their state and how available they are. It’s a co-construction of the intervention in the moment, Daniela says. It’s why clinical reasoning is essential to supporting the developmental process.

To bring it back to the DIR provision of how we do therapy, Maude says, she always worked with intensive models because research said high intensity and high frequency is what changes the brain. She would do 3 or 4 occupational therapy intensives with some weekly services in between and did pre- and post-testing to compare. She would show the parents the beautiful results how the child has changed and how the nervous system has changed. But what really amazed Maude was that the parent reported that the behavior is still the same at home.

This astounded Maude. She felt like the rug was pulled out from underneath her. She had done everything right. And of course, she did everything in a sensory relational way. Next, they did a retroactive study through one of the universities there, Jefferson University, that one of the students did with 100 of Maude’s cases. They knew they were getting the results but some kids just moved on, while others couldn’t do the same with that new nervous system. They realized that there’s a nervous system adaptive response, yes, but there’s also an emotional adaptive response, and there’s a readiness of the emotional relational system that needs to accept the new nervous system.

This told Maude that when we harness the relational flavor of when we have to practice out these practical pieces like praxis, ideation, visualization or visual-spatial, and when we have to put that into play with the relational piece as the pivotal point, the results come in much faster. The adaptive response comes in much faster. That was a clinical piece for Maude to understand, she shares. If they need the first session to only be relational, that’s what they’re going to do because they know that if they go slower at first they can go faster later.

The Focus is on the Process

The relationship is that pivotal piece around which we operate every single day, Maude continues. It’s how we come home to our significant other–that person that we rely on to be there in times of storm. Why do we rely on them, she asks? Because they are in us and with us. So, this is what every single session should look like, Maude insists. Even in using a program like Interactive Metronome (which is a very rigorous program that supports the praxis piece in a very strong way) where the kids are literally clapping and tapping for an hour long, her team has found ways to do Floortime where the individual is going to have their own choices and decide how they want to do it.

Maude says there’s the fact that you have to do it, but they’re going to do it in such a Floortime way that the individual feels like they’ve owned the session, and when they walk out of that room and say to their mom, “I got 14 bursts today!” that pride is there that they got themself through it. And if in the beginning of the session, the child’s not ready to clap or tap, Maude says they’re going to work on how they can get the relationship going first and they’ll forfeit that first 15 minutes. When they get to it later, it will count far more.

The relationship trumps everything. It trumps the precision of what we can do as a therapist, Maude says. We are a world of productivity. We are a world that value you based on what you can do and what you look like. It values output, Daniela adds. Greenspan was intent on focusing on the process of development: the process of growing up not only the child, but growing up the parent, Maude says.

Relational Flexibility and Responsiveness

Maude found the book Raising Parents by Patricia Crittenden very interesting. When Maude is on the floor and the parent is in the room and they’re working their flavours together, and the parent is moving in and then Maude is moving in, it’s the flexibility of how they operate that the child is observing. That flexibility is what we want to see in that child, Maude explains. There are so many social emotional pieces that come way before any productivity pieces. Maude acts as that co-anchor or surrogate parent with that caregiver to provide the structure for the child for this period of time to see that relationships are safe. This allow the child to realize, “I can actually do things I never thought I could do.“

If you don’t have the praxis productivity piece, you often can’t show how much intelligence you have and often this is where pieces go wrong and where people misunderstand and mislabel, Maude says. If the child feels they don’t have a next idea, they move away and we say they must be distracted. They’re not distracted, Maude says. They didn’t know what next to do. Maude wants kids to be understood. She wants to look at the world through that child’s lens. When we do that, we can truly get into the act of presence, and then children can thrive.

The way that children respond is often the way that they think we perceive them, Maude continues. The child perceives the world the way that the parent sees the baby. They don’t have a sense of self yet. Next, the baby starts to imitate, and that imitation is where the self is actually coming into frustration, so that by 6 months of age when they push away from Mommy and pull their hair and touch their cheek, they are realizing the separation between them. The emotional separation comes later, as Daniel Stern and Margaret Mahler write about: the individuation piece. Activity is wonderful. Analyzing activity is great. Doing those things without emotional resonance and relational flavor often turns into wasted time, Maude states.

Supporting the Maturational Process

Daniela thought of Jean Ayres’ little blue book. What she loves about it is Ayres’ language. There is a clinging on to concreteness of words and inability to extrapolate meaning in public discourse at the moment. In the blue book when it’s talking about sensory integration in the child and treatment in the maturation process, it’s the environment that is providing the child with the opportunities to support that maturational process through that interaction. So, whenever there is a disruption to the process due to sensory integration difficulties, then the environment for the child is not enough to support the maturational process.

At the end of that little paragraph, Jean Ayres says there is something in the environment that’s missing. The word that she used is “something” and the goal of sensory integration therapy is to provide that something, Daniela explains. That something is the difference between an activity and an exercise and a therapeutic intervention that supports sensory integration. You can come with the protocols and the checklist and the treatment plans and whatnot, but if that “something” is not there, it’s just not gonna cut it and the child is gonna let you know about that, because you’re gonna see it in the quality of the engagement.

You will see it in the quality of the interaction or you’re going to go down all the way down to felt safety when the regulation gets knocked down because the child feels so threatened. Whatever you presented there, that child did not register it as that “something” that will support the developmental process; it presented as a demand that they cannot meet, Daniela relays. Maude agrees. Then they blame the child or the diagnosis, Maude says. But the label is concrete, Daniela adds, which gets into the idea of uncertainty.

The Risk of Uncertainty

Our world is feeling very chaotic and very unpredictable. Risk and uncertainty are bundled together, Daniela says. The more uncertainty, the more threatened you feel. As a parent, you can cling to a diagnosis because it’s going to open funding and provide therapy and a rationale of behavior that’s not making sense to you. That’s why presence is so key and sometimes shuts down thinking, Daniela continues.

Daniel Stern says that making sense is an imperative of mental life, Daniela continues, so you can put a diagnosis there, which is something concrete to hold on to and explain behaviour, but even if the child has severe and profound intellectual disabilities, they’re still making sense how ever they can make sense. It’s an imperative of mental life, she asserts. When you put a diagnosis there, you make it deficient and there is nothing deficient about how ever someone can make sense.

Another tension Daniela lives with is that when she is trying to troubleshoot and figure out with her child which transitions are hard in the moment, it’s her assumption and interpretation because she is not in his body, sensing and perceiving the world on his terms. Depending on how attuned and knowledgeable of your child you are and how much time you spend with them, that influential process carries risk, Daniela stresses. You can have high likelihood of making the right inferences, or you can have a low likelihood of making inferences.

That’s why knowing the child is so important, and that’s where knowing about DIR comes in: understanding development, understanding the individual differences, and understanding the relationship. So, you can support that inferential process and get to ideas that are closer to that lived experience of the other, but you’re not going to know because you’re not in their body. We have to feel comfortable with that uncertainty because it allows movement for understanding and troubleshooting, Daniela concludes.

Conclusions

The essential piece for change is the availability of variability which is the flexibility inside of the nervous system, Maude states. If the nervous system state is asking for predictability, structure, and sameness, it’s feeling overwhelmed. We have smart systems. Our systems are inborn in us to adapt with whatever the environment is. So, there’s no such thing as maladaptive behavior which used to be the term everybody used. There is only adaptive behavior and we need to let go of the lens of saying that when behaviour is not what we expect or is not publicly appropriate, or is not appropriate to the situation. Even though that behavior doesn’t look like the ones that we may want to see, it’s still adaptive from the lens of the child.

If we can figure that one out, Maude asks, and keep our lens open to see their behavior as a communication about how they’re adapting to the environment, many more kids will flourish. Maude has been working with autistic adults who are coming in more and more now. These adults are all talking about almost feeling like they were victimized by the environment because they could never really get to their full sense of being because they never knew what it was. They’re pivoting around an anchor that wasn’t anchored. Listen to what those autistic adults say. There’s value here, because if we can intervene from childhood forward to provide the essence of the child to the child, we have so much more room to move into flexibility for variability and also curiosity, Maude suggests.

I summarized that I heard that growth is being comfortable with the uncomfortable, and we determine how much we can stretch that discomfort to provide growth. That’s that whole adaptation process that Dr. Gordon Neufeld talks about it. If you’re stuck in a frustration circle and not feeling understood, you can’t adapt to that next step. And when Maude talked about a child’s body needing to be ready for this new nervous system emotionally, it made me think of an example from my son’s recent OT session.

Our OT is a wonderful Floortimer who worked with Dr. Stuart Shanker in the DIRFloortime York University study. As Maude knows, my son can get enough propreoceptive input, but in passing, I mentioned that he doesn’t like the weighted blanket on. He wants to kick it off. Our OT posed a curious question. Maybe it’s scary for my son to actually feel what it’s like to be in his body, because he doesn’t typically feel register that feeling, and having that weighted blanket is making him feel that, and so that’s uncertainty. It’s one possibility.

In response to Daniela talking about uncertainty, I referred to the trauma podcast episode that I did with Maude because when you don’t have that experience of feeling understood with another person, there’s trauma there and we want to know how we can work with that.

I appreciate the time and thought Maude and Daniela brought to this discussion. If you found this episode helpful and informative, please consider sharing it on social media!

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