What is Floortime Therapy?

Sarah Taylor, AutismBC’s regional coordinator for the Vancouver Island region, talks about floor time with occupational therapists and certified floor time practitioners from Little Buddies Pediatric Therapy, Keith Landherr and Alysha Paiaro. Keith is working on his PhD in infant mental health and developmental disabilities, and Alysha is an in-play project consultant.

This transcript has been edited for length and clarity.

Sarah: If you could just start off with maybe some basic principles of floor time, and a little introduction to what that means, that would be great.

Alysha: The biggest thing that we always want to start with is just recognizing that it’s all about relationships. What it is and what it isn’t: DIR floor time is an individualized approach designed for children with autism spectrum disorder and developmental delay. It’s an approach that’s tailored to the unique strengths, interests, and challenges of each child. It’s a model that highlights the power of relationships and emotional connections to fuel development. What it isn’t is rather than targeting skills and isolation, it focuses on nurturing critical, social, and emotional developmental milestones for lifelong learning.

Alysha: This is an approach that is broad, and we’re going to kind of slide across the surface of things and touch upon the broad points of it, but what’s really important to remember is it’s a developmental approach that’s designed to foster foundational learning capacities that we need for all levels of learning, from basic self-regulation skills all the way up to high-level PhD academic-type thinking. These are skills that follow us throughout the lifespan and serve us every single day.

Alysha: In DIR, obviously the ‘D’, the ‘I’ and the ‘R’ — these are the core principles that guide the model. So, you can think of the DIR as the theory behind it, and when you hear, “floor time,” that refers to us putting these principles in action. It’s kind of the practice. The play piece is when we’re literally on the floor.

Alysha: Within the DIR, we’ll start with the ‘D’, and that stands for developmental. This describes the development from the perspective of the individual, where they are, and where they’re headed. We’ll talk a little bit more about that and what kind of components are on the developmental ladder that we focus on in this model.

Alysa: ‘I’ refers to individual differences which are the unique ways that each of us take in, regulate, respond, and really make sense of the world around us. Our differences aren’t the exception to the rule. Differences are the norm for who we are in this world as beings, and to tailor an approach such as this, we want to do what we can to try to learn as much as we can about the individual differences of the child, the family, and ourselves while we kind of negotiate this relationship and support development and learning.

Alysha: Within that, I’m already talking about the ‘R’, that relationship piece, and within this model we’re always recognizing that relationships fuel development. It’s within that context of safe and loving, responsive, resilient relationships that learning takes place, and we always want to put that at the forefront.

Alysha: Keith brought up this quote earlier this morning as one of his favorites from Stanley Greenspan. He is one of the founders behind the DIR model with Dr. Serena Weeder. He said, “Self-regulation isn’t just something, it is everything.” And I thought we’d start there.

Alysha: When we think about development in our developmental ladder, our very first foundational capacity is self-regulation. And being able to regulate those internal and external processes that are making sense of who we are in this world and around us. Regulation is critically important for infants, but it’s also really important for us as adults and what we need to do to get ourselves ready for driving, sharing a meal with our family, or going for a run. We all self-regulate in different ways, but without that, the whole pyramid can be thought of as crumbling.

Alysha: We move up from there. We start with regulation, and then we move into the next capacity, which is engaging and relating with people. So, I’m showing interest in my social world, and wanting to connect with my parents, my siblings, my loved ones. And after I fall in love with those people, I want to be able to communicate my intentions. And we start with just our basic intentions, a simple reaching out, which is such a powerful gesture to say, “Hey, I love you. Come closer.” And as that’s cooking, and as we’re going, this communication broadens.

Alysha: Instead of just a kind of a gestural intent, we start being able to communicate more complex ideas, and stringing together what we often call “circles of communication,” that ability to have that call and response together with somebody that we love, or somebody that we’re relating with or playing with, and keep those communication circles going. Within that process we’re going to build even bigger again and start going into the world of complexity of emotions and symbols, and then finally into abstract reasoning.

Alysha: Within these different developmental capacities, a lot of the time where we’re working is these early foundational capacities. One to four maybe, and then we dip into those higher ones. But like I said, these are capacities that I’m working on all the time every day. I still do this.

Alysha: When you’re thinking about, “What is a floor time session going to look like for my child?”, and thinking about an entry point, we often start with that assessment of understanding your child’s developmental profile – what capacities are really solid versus which ones are a little bit shaky. And that recognizes that this developmental profile is not linear. We can have capacities for logical thinking and reasoning, but also still have some really shaky vulnerabilities when it comes to regulation. So, we’re moving through that process of jumping it up high, but then maybe we’re recognizing, “Hey, things have gotten a little bit more challenging. We’re in a bit of sensory overload, or this motor demand is just a bit too much. Let’s back it up.” This is the context that we’re referring to in the background.

Alysha: The next one is that ‘I’, so we’ll talk about a little bit of the individual differences piece. Another quote from Dr. Greenspan is, “Every child wants to interact. They just might not be able to due to their unique biology. So as soon as we notice this, we find a way to get into their world until we see that gleam in their eye and then we do it over and over again.”

Alysha: We strive to explore these individual differences and make sense of them. And if we’re able to better understand the sensory processing capacities of a child, their visual spatial skills, their language capacities — this is all incredibly important information that helps guide us as OTs or as parents to tailor how we’re interacting with the child in a way that’s directly informed by their individual profile.

Alysha: A concrete example is thinking about some children that are really sensitive to loud noises. So, then I’m going to be really cognizant of the tone of voice that I’m going to be using or making sure that our sessions are not at the same time as a basketball game playing in the field next door. But it can become quite a bit more nuanced than that when we’re really looking at modulation skills and the complexities of motor skill acquisition and sensory processing.

Alysha: We’ll move a little bit further into the ‘R’ piece, and just building into that place of, “There’s no greater feeling than being understood.” It’s within these relationships I mentioned that we grow and we learn. And it’s within that relationship of understanding and empathy that we feel like we want to take a little bit of a step outside of our comfort zone. And it’s those little steps into that unknown, into that challenge, that continue to foster learning. But we want to really prioritize that that relationship has to come first. And that’s really imperative.

Alysha: This really differentiates, in my opinion, between a relationship-based approach like the DIR model versus more behavioral approaches that would prioritize the skill building or the skill acquisition first, and then dissecting what is needed in that skill; let’s bolster those components.

Alysha: Those are kind of top-down approaches, and this is when we’re starting at the base of everything. Let’s start with safety and relationship and knowing and empathizing and then from there we’re going to broaden and see what kind of skills are possible in that space in a really meaningful way for all of us and the children.

Alysha: I think I spoke a little bit about this, so we just want to recognize that affective interactions build social and emotional development, intelligence, and morality. Affective is a fancy word for emotional exchanges. Affect can be those big animated facial expressions of smiles, but affect can also be really subtle and nuanced. It can be just a noise.

Alysha: All of these different things that allow us to attune and show that we are witnessing and trying to share in these experiences with a child – we do that through these affective or emotional exchanges. And in the long run, maybe we’ll build to a lot more complicated communication, but we’re always using that affective piece to keep things going and build that resonance.

Alysha: There are the broad sweeps of the theory around the ‘D’, the ‘I’, and the ‘R’, and then as I said, floor time kind of refers to: “How do we put this in practice? What does this mean? What would this actually look like if I were to bring my child to a floor time session? What am I going to be witnessing or what am I going to be going for if I want to do floor time with my child?”

Alysha: Here’s a summary of some of the primary principles of what a floor time session is. We’re going to be thinking with this background of those developmental capacities, profiling the child to make sense of where they’re at, making sense of those individual differences, and first and foremost, wanting to aim to attune to where that child is at affectively. “Are we excited? Are we a bit nervous? Are we just overwhelmed and I’m not even feeling grounded in space right now?”

Alysha: We’re going to start there. And using that power of attunement to try to support regulation with first co-regulation. We’re going to regulate together. And continuing to regulate together in this … flow [or] co-regulation, because it’s an interplay between both of us together to make sense of that. And over time, we want to build to self-regulation skills and self-regulation capacities for supported environments and tailored environments, but also into kind of unpredictable unknown environments, which is really challenging.

Alysha: Another really big principle – and you’ll hear this lots – is follow the child’s lead. We like to tweak this to follow the child’s motivation. So, it’s not about a “follow the leader, the child goes there, so I’m going to follow the child and we’re going to do that.” What this model challenges us to do is to think about what is meaningful and motivating for a child that we’re working with, and use that as a guide around, “What types of interactions and activities might I want to set up?”

Alysha: If I know that this child just loves movement and we’re really working on getting that flow of communication happening and shared emotional experiences, I would be remiss to think, “I should do that just sitting on the floor. I’m going to start with movement and see, ‘How can that set the stage for more complex communication?’”

Alysha: So, following their motivation, following their lead, we’re always trying to aim for circles of communication and seeing just how many we can get going in a long flow. We’re thinking about the balance of, “’I’m going to initiate, so I’m going to open those circles” … but I also want to be really careful it’s not just all on me to open all those circles, right? It’s also looking at the children and the clients. What are they opening? And how am I responding to those moments with a subtle gesture or a really clear response?

Alysha: We do want to expand and challenge and broaden that zone of development when we feel like that’s the safe thing to do to nurture growth. We’re not always staying in that little focus of safety necessarily. That’s a really important place to be and to be able to get into when we need it, but we do want to expand and challenge when it makes sense to do so; when it’s appropriate for that child.

Alysha: And then finally, self-reflection is incredibly important for us as clinicians, for the parents and the caregivers, the teachers, the BIs, the care teams for us to be thinking about, “Okay, I just had this interaction and sometimes I feel just boosted and filled with energy.” Let’s take a minute though to think about why. “What was it about those interactions or that last hour that’s really got me feeling so good?” Because there’s going to be these incredible little pieces of information that are so powerful for us to share with other people; maybe other caregivers that are working with that child.

Alysha: But there are also going to be moments of things just not quite working, and self-reflection and being able to try to make sense of, “What are our individual differences? What are we bringing into an interaction? Is there a good fit there with us and the child? Or were we actually at odds today and that made our relationship really tense? And this wasn’t the best situation; how might I tweak that and change that moving forward?”

Alysha: So that reflection is continuous. It’s ongoing, and parent coaching is a really important part of this model and we’re always encouraging families that want to participate in sessions. So, we can all be on the floor together and continue to have these reflective conversations to continue to make sense of, “How do we get to tailor these interactions? How do we get to play together in the most fruitful way that just feels good?” It can make it really jargony, but sometimes that’s the best queue to know if we’re doing floor time right. Did you feel it? Did you see that gleam in your child’s eye? If there was that gleam, awesome! Let’s follow that and see where it’s going to take us, and what kind of skill opportunities are going to open up.

Keith: And I think also we can do that out loud with the child as well, and so that we can just say, “Oh, I didn’t mean to scare you” or, “Oh, I didn’t realize.” Doing that without that many words like, “Sorry about that,” so that the kid is seeing you self-reflect, and so they know you’re thinking about what they’re doing — it lets you do it in real time as well. If there’s other therapists working with another child in the room, they get to see what we think the child is thinking. And then Alysha and I go upstairs and do it all over again without the kids there, so that we also encourage that reflective process. Self-reflection is also a group process at times.

Keith: I just wanted to make sure everyone knew it would be something you’re working on with the kids and as they get up to level six … what we might try to get from them might be a little bit greater. When they’re just struggling with regulation, just as when we’re struggling with regulation, we’re really not thinking about self-reflection. I always use the “Your flight’s been cancelled at the airport” analogy. It’s like, “I’m not very regulated during those moments and the people at the counter are probably not that regulated.” And you’re kind of knowing that you’re not going to be engaging in higher level thinking, and that when the kid is in that state too, they’re not going to be. We kind of go back to just trying to help them co-regulate, or figure out how to regulate by themselves.

Sarah: Yeah, that actually segues nicely into one of the questions was, “Would parents or caregivers be able to use these techniques at home?” And it sounds like absolutely they can.

Alysha: Absolutely.

Keith: There should be a bit of compared coaching that happens, and the original design was for parents to be able to do things at home so that they would be able to have a lot more hours of practice with the children, having specific times to do floor time versus just trying to interact with them so they can get a little practice under their belt. Alysha and I will floor time relationships with people, interpersonal relationships, or my family members when I go home to visit — things like that. It’s quite helpful.

Sarah: Now, is this aimed at a certain age? Or anyone could benefit?

Keith: I think that anybody could benefit. We have had children that started at a much older age, and the nice thing is trying to help them figure out when the first four levels fall apart for them, and then how to repair the relationship so that they’re more able to engage in those higher levels. It’s great, because it makes the flow a lot easier for them, and they seem to enjoy their relationships with people more after that.

Keith: But I mean, it can be at any age, and it’s the practitioner or the parent who just needs some guidance figuring out where they’re at in terms of a developmental level and then what kind of scaffolding strategies you would use to help them regulate as you’re bringing them up to a higher level, or following them up to a higher level sometimes — which is great. Sometimes you have to know when to just follow them and realize that they’re doing something incredible, and just let it happen and just make sure that they know you’re interested.

Sarah: Yeah, one of the questions — and you covered a lot of this — was, “Is this is helpful for self-regulation?” But clearly, absolutely it is, because that was one of the first things you mentioned.

Alysha: Yeah, absolutely. Absolutely.

Sarah: How would this work in conjunction with another type of therapy? Maybe more behavioral based therapy? Or would you want to just focus on floor time?

Alysha: Many of our clients have full care teams with behavior consultants and BIs and speech therapists. And then we also have some families that say, “I’m building a floor time-informed or a relationship-based informed team and that resonates the strongest with us.”

Alysha: There are consultants out there that are learning more and more about these relationship-based approaches and are using that information to inform the style of practice that they offer. But no, there’s nothing that says that this would need to be done in isolation necessarily. A lot of the time because so much of it has to do with us getting to know who we are and getting to know our children and the children that we’re working with, that is just incredibly important for anybody that is going to be working with that child, right? It’s important today, it’s important on the playground, and it’s going to be important in a different context.

Alysha: We bring our unique Occupational Therapist (OT) lens, which is fantastic for helping to understand a motor skill profile and the sensory profile of the children that we’re working with. We would kind of argue that that’s integral information for anybody that’s working with this child to really go the distance, so to speak.

Sarah: Now, if someone was looking for someone who did floor time, are they always an Occupational Therapist? Do they need to be supervised by an OT or could they have trained separately?

Keith: No, Stanley was a psychiatrist. It’s a multi-disciplinary approach. There is a behavioural consultant I know who is at the second level of certification.

Keith: Today I was doing floor time, and a little bit of behaviorism, right? And I didn’t want the outcome that the kid was looking for, and I wasn’t going to reward him for the way he was doing it. He wanted to grab something out of my hands that I was going to give him anyway. And so, I said, “Boy, I was going to give it to you anyway, but if you grab it, I’m not going to give it to you, because as soon as you ask me for it, I’m able to give you what you want. I’m going to give it to you, but I won’t give it to you when you do that.” And then he says, “Why?” It’s like, “Well, because I don’t really like when you do that, because it kind of makes me sad.” It’s using that, depending on where the kid is at, to bring that piece around.

Keith: Some of the motivation would really be around looking at the relationship as part of the reward; us being able to laugh together and have fun together, and for us to figure out a problem together, including trying to get the kid’s idea to work. Of course, getting a ball to roll up the hill won’t work, but we can certainly give them a go and see why it won’t work, because it’s just the way gravity is, right? It’s kind of a higher-level concept for them to figure out, but it’s great for them to see that we’re both trying to do it, and neither of us can make it happen, so maybe that’s just not the way it works.

Sarah: That actually leads in really well to the next question. If you’re following the motivations, how do you approach redirection of negative [experiences]: Meltdown, self-harm, those sorts of big emotions?

Keith: If someone’s trying to hurt themselves, I do try to figure out what’s going on for them sensory-wise that they’re doing this; are they trying to block out everything else by creating a really intense sensation in their body? I think that often helps: Saying, “Oh my god, that was really hard for you; oh my god, I don’t know how that happened.” And the more they notice that I know what they’re feeling, it tends to go down a little bit, because when they feel like I’m understanding what they’re trying to communicate, it often brings some of it down. And knowing that there are some cases that are very, very difficult … but those would be very specific approaches for those children. Usually, Alysha and I do a lot of consulting with the younger therapists that we work with so that they would be able to do that as well as parents.

Alysha: Something I want to touch on a little bit too is that when we think about these “negative emotions,” those are just as valid and important for us to sit in and explore and make sense of as the feel-good emotions, right? We’re not always perfectly happy people. I don’t want to be that plastic person, right? And I certainly don’t want to nurture that in any of the kids that we’re working with. But it’s making sense of those feelings and working together on emotions that are more challenging, whether it’s frustration or anger or sadness.

Alysha: Oftentimes, those can be really dysregulating and overwhelming for the kids that we’re working with, right? And we tend to kind of say, “Well, I know that’s super dysregulating, so maybe I’m going to try to steer clear of that.” Well, sure, that kind of helps in the short term, but these are natural human emotions, and we want to work so that those aren’t quite so profoundly dysregulating, right? I think they all have a little bit of that kind of effect on us.

Alysha: If I get suddenly startled or a loved one does something that really hurts me, my foundation is going to be rocked. My regulatory skills are going to change, and I’m not going to be able to do what I usually can that day. But it’s about trying to work through that when holding that space and supporting that social emotional learning piece that Keith was talking about.

Alysha: I was getting yelled at a fair bit by a child, and it really wasn’t about me. They were coping with a lot of really big emotions, but a lot of it was kind of being funneled at me. We were in a space of learning where it was okay for me to say, “When you yell at me like this, that hurts. That doesn’t make me want to be with you anymore. That’s really hard.”

Alysha: That’s not language that I would necessarily use with everybody, but for this child, it was appropriate. And it was really important to differentiate that it’s okay to express anger, but that it can be really hurtful when you target it at people that you do care about, and there will be social fallout for that.

Keith: Using the relationship piece, you do have a relationship with them. If Alysha was with a kid that was doing this, she might say, “Keith, this guy’s doing this a lot.” And then I might make sure I’m in the room while she’s there. Then when he does something that is even slightly towards that behavior, she gets to say, “You know what? I need a minute. I’m going to go out of the room.” And her withdrawing that even for 30 seconds tells him, like, “We can’t do that and then have this same relationship.”

Keith: But you know, it kind of hurts. Often those are the kids actually who have a really, really high pain threshold, so they’re actually not feeling pain as other people are or other kids. They could be hitting you and they have no idea what you’re talking about because it doesn’t hurt them when somebody does that to them — and for them to just know that whatever that is, you have to honor the other person’s limit. That seems to bring it around faster than anything.

Keith: And then realizing too that some of these kids often have like, a delayed processing or reception of the low registration of the sensation. Those are also the kids who wind up having limited interoceptive capacities.

Keith: It can get pretty complicated because those are often the kids who will do things that are self-harming. And half the time they don’t even feel it. That’s part of it. And so, when the kid does feel something, they’ll tend to feel bony pain before they feel soft tissue pain. Just letting them sit — because when those kids get hurt, we get shocked, and we’re like, “Oh it’s okay, it’s okay, it’s okay.” And instead of like, “Wow that really hurt.” Letting them cry it out — “I’m going to stay with you until this goes away,” so that they can just better process the emotions that we find harder, more challenging to be around.

Keith: But it also helps them feel more secure, so that the next time it happens, the neurotransmitter explosion that is happening won’t happen quite as much. It won’t be as much of a storm because they know they have a circle of security around them.

Sarah: For behaviors like self-injurious behaviors, regression, how can you explain things to a child who also has an intellectual disability, or very limited language skills? That was from one of the chat questions.

Keith: I do a lot of miming. Like today, there was a kid who wanted to get onto the sling swing we have, but she was on top of a small air cushion. And so, when she went to sit down like she usually does, she misjudged the space and she tumbled onto the cushion and landed on her backside, and then was so shocked about what happened that it took her a while — she couldn’t figure out what happened. And so, I went over, and I mimed what happened. And she got to see what it looked like, and I said, “Oh, my bottom missed the swing.” And then she looked at me, thought about it for a minute, and then got up and tried again. Sometimes that kind of demonstration helps quite a bit.

Keith: But they communicate very differently, and so it can be a bit of a challenge. I mean, I was around a lot of babies when I was younger, and I waited tables in very busy restaurants that were loud with people who didn’t speak any English. It was a tourist restaurant, and so I just figured out how to mime and read people’s faces. And, you know, we can tune in and get a bit better at that, and sometimes using some visuals helps as well. Sometimes it doesn’t have to be a word. It can be a different shape or squiggle, or splat — those kinds of words that say what they mean or sound like what they mean rather than trying to work on the vocabulary.

Sarah: Yeah, that’s great. Is there data collection during these sessions or by parents?

Keith: The data collection isn’t required. The studies that were done used different markers that were based on standardized assessments rather than just data collection. There was a control group, so for the parents, what we asked them to do is to write down what they understood to happen, and also, we use video. We have them show us a video of them working together, so the data’s right there. We use video just for our own reflective practice, because you watch the video and there are times when you say, “Oh my gosh, I can’t believe I missed that they were trying to do. They actually figured out what I was trying to say, but it was right after I turned away.” It’s that sort of thing.

Keith: Using that technology is fantastic. That’s part of being able to coach somebody and how to do it better. We certainly can do this quite a bit with parents or with BIs where we use OTAs as well and it’s pretty good.

Check out Little Buddies’ website to get in touch or email [email protected]. The Affect Autism website can provide more resources, and you can find more talks like this on AutismBC’s YouTube channel.