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Development Starts With Relationships

Present day.

I take a few deep breaths to get myself centered and grounded. I want to be fully present for the next kiddo who is coming in to play with me today. Joey dashes past me to the motor room, which is filled with swings, toys, and therapy balls. I say hi to his mom, and we greet each other with warmth.

As Joey’s mom and I walk back to get started, Joey is already pacing from one end of the big room to the other. When he gets excited, Joey runs around and squeals loudly. He balls his fists up and crosses his eyes. When we walk in, Joey stays in motion, but throws a few fleeting glances our way. If I didn’t pay close attention, I’d miss him taking in the visual information. Joey is checking in to make sure his mom and I are engaged and happy. It always helps Joey transition into the session when he sees that his mom and I have a connection. I make sure to give him the time he needs to explore the room and take in all of the good feelings that we have fostered over the past year.

I sit down near Joey, who looks out the window before he heads across the room again. I open myself up for him to play with me. I know that he loves basketball, so I bounce one near him and pause to see if this entices him toward me. I roll the ball side to side on the windowsill and wait. I do not tell him to stop pacing. I do not tell him to look me in the eyes. Rather, I ground myself and become aware of the space we are in. Right here. Right now. Hmmm. Basketball is not interesting today. Let me wait. And watch. And wonder— about how to best support his regulation, so that I can eventually woo him into a shared world with me.

Initially, Joey took time to warm up to me. Now, he is not only comfortable in my clinic, but he is thriving in his home and school. He is on a wrestling team and he enjoys playing with his siblings and cousins. Joey had been inside other clinics where he was asked to do many things that, at that time and in those moments, were beyond his developmental capacity. Those sessions did not seem to consider the different ways that Joey takes in and processes sounds, sights, and movement experiences in his environment. And from the reports, it doesn’t sound like Joey had fun, or found any relationships that made him feel safe enough to come out of the sympathetic fight/flight state that he was in. According to his mom, those sessions caused him such extraordinary anxiety and stress that he was given secondary diagnoses of anxiety and an attachment disorder, which now accompany his primary diagnosis of autistic spectrum disorder.

Twenty years ago.

In the year 2000, I was as a young and very new pediatric physical therapist. About half the children I worked with had a medical diagnosis of “global development delay.” Since then, children in the U.S. have been diagnosed with developmental disorders such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), developmental coordination disorder (DCD), and, more recently, executive functioning disorder (EFD) at an alarmingly increasing rate. The vast majority of the children I met with gross motor delays also had some sort of regulatory challenges. Regulatory challenges are the result of either an over-aroused or under-aroused central nervous system, which often stems from difficulty with sensory processing. Sensory modulation can present as sensitivity to textures, light, sounds, or movement, or it can present the opposite—an under-responsiveness or low registration of sensations. Some children with sensory modulation differences need excess amounts of touch, wrestling, movement, or noise. To others, those same sensations are so overwhelming to the central nervous system that they can be perceived as painful, and therefore scary. Sensory processing and emotional regulation are inextricably linked, anatomically and physiologically, within the brain and body’s autonomic nervous system. When a child has sensory modulation difficulties that are not adequately supported, the child’s nervous system may be in a perpetual state of fight/flight (over-aroused), or a state of freeze (under-aroused).

Back then, I knew that when I connected with children and their parents in meaningful way, and when I trusted my instincts to put a child’s sensory processing and comfort level (regulatory state) first, children made progress toward developmental motor goals that yielded a hundredfold increase. At the time, and especially now, behavioral approaches to developmental delays remain the recommended route for “treatment.” Challenges with self-regulation may manifest as inattention, difficulty sitting still, fidgeting, and difficulty with stabilizing eye gaze. I argued with colleagues about the importance of therapists having a genuine connection with each child, of meeting sensory processing needs as a way to promote motor development. I knew that fostering a connection was the way to maximize outcomes for their little developing bodies’ balance, coordination, flexibility, and strength. But I couldn’t find the science to support this instinct. Armed only with instinct and a new grad’s understanding of how the vestibular system supports postural control and balance, I was about to embark upon a 20-year mission to pinpoint the science behind why development starts with relationships.

Regulatory challenges quite obviously impact a child’s ability to enter into meaningful relationships with caregivers. A child with regulatory challenges needs more space and time to connect with the sounds and sights of the environment, including preverbal affective cueing from his caregivers and therapists. The very early developmental capacities, such as smiling reciprocally and sharing attention long enough to follow the caregiver’s gaze, are at the very foundation of shared problem-solving, which is the critical foundation of a child’s motor development (and yet it is the element most often missed).

Over the course of the past 20 years, I have grown increasingly concerned about the overuse of widely accepted behavioral approaches that most doctors, educators, and allied health professionals recommend as a source of support for our youth who have developmental differences. While behavioral approaches have a very important place in our healthcare system when a child is experiencing behavioral challenges, they are inappropriate to use with a child whose developmental capacity is not synchronous with what is being targeted. It is not appropriate to test a child’s ability to sequence pictures cards when he may not be able to stabilize his gaze long enough to see them, and he is rarely able to sequence motor steps with his body.

Using behavior plans that are beyond the developmental capacity of a child are like asking me to do a calculus problem if I didn’t know how to add or subtract. No matter how many rewards or breaks are offered to me, if I don’t have the foundations for that skill, I will not be able to do it. When I am asked repeatedly to do something that I am not in the right neurological state to perform, I will try to leave the situation—and if I cannot get out of the situation, I will likely end up crying in frustration.

Within the first few months of working in pediatrics, I realized how a developing child’s sensory apparatuses, which are inexorably linked to that child’s motor development, are also intricately connected to social and emotional development. The link is the central nervous system— more specifically, the role that the autonomic nervous system plays in the development of a child with sensory processing differences. If a child had sensitivities to textures or tactile information, this meant that they were quicker to enter a state of fight/flight. And therefore, they would have an emotional response, as well as a motor response. If another child was terrified of having his feet off the ground (“gravitational insecurity”), this child would also spend a great deal of time in fight/flight— another emotional response. If someone had auditory sensitivities, or became terrified of hand dryers or toilets flushing, this child would also be in a relative state of fight/flight. It became clear that in order to address motor outcomes, we must address sensory processing issues at the same time.

Now, I knew that these kids had to “let in” the sensory experiences, so to speak, or somehow access appropriate sensory information, in order for their brains and bodies to know where they existed in space, so that they could balance and coordinate the two sides of their bodies for motor function. As mentioned above, many colleagues perceived the etiology of a child’s emotional reactivity not as altered regulatory states needing support, but as behaviors meant to be extinguished. I heard many therapists, physicians, and educators refer to a child’s tendency to stay in perpetual motion as an avoidance tactic. I heard people refer to a child’s vocalizations or repetitive motor patterns as “meaningless stimming.” In contrast, I felt observing these tendencies were very meaningful, and gave me a way to gain insight into a child’s nervous system. I saw a child in motion as needing movement to support regulation, and a child who closed her ears as needing less sound to feel comfortable. I tried to support the needs of the child, and waited to see if this helped them to engage with me. And with lots and lots and lots of trial and error, when I got it right and was able to meet the child’s regulatory needs, the child became engaged. And then they were able to organize their little bodies for crawling, walking, catching a ball, and so on. The key was the relationship. It was our shared world.

In the late ’90s, I was taught in one of the best physical therapy schools in the U.S., and I learned a great deal about how the autonomic nervous system (the sympathetic and parasympathetic systems) works to mobilize us against perceived danger, and how it serves to calm our bodies and relax our defenses when we feel safe and secure. I learned that the vagus nerve, the “wandering nerve,” is the only cranial nerve that traverses from the brainstem directly to our internal organs (heart, lungs, and digestive tract) without spinal nerves as an intermediary. I learned somewhat vaguely (no pun intended) that the vagus was connected to parasympathetic activity, and helps put the brakes on our heart rates, our digestion, and so forth, when we are ready to “rest and digest.” But I had no idea that this would later become the scientific justification for why my own relationship-based approach to physical therapy worked. I had no clue that it was through what Dr. Stephen Porges, author of The Polyvagal Theory, calls our “social engagement system” that the vagus nerve is stimulated to broadcast signals of safety and comfort.

In 2004, I met a Maude Le Roux, who introduced me to the work of Stanley Greenspan, M.D. Maude is a brilliant occupational therapist and DIRFloortime expert. She was a supportive and thoughtful mentor who fostered self-reflection and collaboration. I have truly never been the same since. The work of Dr. Greenspan and his DIRFloortime model explain and identify the earliest developmental capacities that lay the groundwork for all development (motor, language, emotional, social, and cognitive). D.I.R. stands for a Developmental, Individual differences, and Relationship-based model (pronounced saying each letter as an initialism: D.I.R.). It is a framework of nine developmental capacities, which, when understood and implemented appropriately (a feat easier said than done), allows clinicians (doctors, therapists, and educators) to optimally support a child with developmental challenges to grow and progress along the developmental ladder through respect and scientific foundation.

The DIRFloortime model is a research-based and scientifically sound approach through which therapists can promote ways to interact with children and their families with respect, curiosity, and the premise that each individual has the capability to connect and relate to one another in meaningful and supportive ways. This model prioritizes the most foundational capacities of development, and assumes that with adequate support, every child with regulatory developmental differences can attain these capacities. It also maintains that practitioners who work with children must have a comprehensive understanding of development. This ensures that children will not develop secondary “behavioral” diagnoses, which are precipitated by asking more of them than they are capable of doing.

Children need to be given the proper amount of time to initiate, connect, and trust. Sadly, at this time, many doctors and behaviorists who prescribe programs for elementary-age children and adolescents do not have even a basic understanding of the developmental processes they have not mastered. Not because these children and adolescents don’t have the capacity to build self-regulation, shared attention, and the shared problem-solving necessary to start to enter the world of symbolic thinking (and eventually comparative and grey-area thinking), but because the recommended treatment approaches have not supported these critical foundational skills. As such, they have often pushed these children into further states of dysregulation, fight/flight, and even, at times, full shutdown.

Dr. Stephen Porges maintains that “when the social engagement system is working and downregulating defenses, we feel calm, we hug people, we look at them and we feel good. However, the two defense systems take priority when risk increases. In response to danger our sympathetic nervous system takes control and supports metabolic motor activity for fight/flight. Then if that doesn’t help us become safe, we recruit the ancient unmyelinated vagal circuit and shut down.”

In terms of motor development, infants do not learn how to reach by reaching for inanimate objects. Rather, they learn how to reach through the desire to get closer to a loved one’s face. Infants first sustain regulation and interest in their world by taking in the sights, sounds, and experiences while being able to stay awake, alert, and interested. They then develop back-and-forth shared smiles and coos in response to others in their world, in order to engage with them. Children with sensory and developmental differences often skip this phase of development, even though they have the capacity to meet them, because their nervous system is in a state of fight/flight or shutdown.

Porges’s extensive research and work, summarized in The Polyvagal Theory, has helped to clarify that when a person is in fight/flight, their middle-ear muscles relax and present with less tonicity. This laxity mechanically makes the muscles more sensitive to low-frequency sounds, and less likely to extract high-frequency sounds from the environment. This middle-ear muscle laxity also negatively impacts the person’s ability to stabilize their visual gaze. Our autonomic nervous system is designed to help us mobilize and escape danger. However, when a child with sensory differences is in perpetual fight/flight, and this becomes his regular state, his ability to access the very system that he needs to calm his brain and body are lost. He loses access to the social engagement system because his gaze is hard to stabilize; he loses access to hearing soothing high-frequency voices because his ear muscles are trained to detect and hear only sounds of danger. He needs a person who can wait with him and support him to slowly come out of fight/flight.

DIRFloortime practitioners are skilled at using their affect and preverbal signaling to indicate safety and closeness. They presume competence of every child, despite their regulatory state. A DIRFloortime practitioner waits and respects a child’s needs for movement, vocalizations, and avoidance as ways that the child is able to communicate his needs and feelings. And when the child initiates interaction with the practitioner on his own, he knows they are connected and the child is ready to begin climbing the ladder of development through a safe and secure relationship, which is just how development proceeds for every child that does not have sensory and developmental differences.

And so, the paradigm shifts from behavioral approaches to understanding that development is relationship-based. Therefore, the strategies implemented by anyone working with a child should have their foundations in relational engagement and the back-and-forth flow of affective signaling. Other approaches, such as behavioral approaches, may have some impact, but they are not long-lasting, and they are certainly not meant to be used for extensive hours at a time. An approach that only considers functional outcomes of behavior misses the root of any challenge, and as such, may impact only isolated skill sets, or have a more temporary impact on the targeted behavior.

Our common experiences unite us. We all have unique individual characteristics, and we need shared experiences to give meaning to our actions. Our desire to connect with others—and yes, I will argue it’s also a biological need— is what gives purpose and meaning to our words, our actions, and our very existence. When it comes to supporting our children with developmental differences, there is but one mantra that should be held true by every healthcare professional and educator: Presume competence, and from that presumption, respect every person’s need for connection as the guiding principle for all intervention. When we approach every child as an individual with the very same desire and need to feel connected, to feel loved and valued, we will put our relationships first. And that will foster their development.

Present day.

Joey is not interested in playing basketball. I wait, I watch, and I wonder where he needs me to meet him today. Like me, Joey comes in regulated and ready to engage on some days, and on other days he needs more comfort and support. I see Joey eyeing up a stack of drumsticks in the corner. I go over and place two next to him and begin rhythmically drumming my own two sticks on the windowsill. Joey doesn’t look at me directly, but he picks up his sticks. He starts to match my rhythm. We drum in tune for a while, and then I get brave and I change up the rhythm. I wait, and slowly Joey matches my rhythm.

Over the course of the next five minutes, Joey and I take turns changing the drumming rhythms and getting in sync with one another. I notice Joey looking into a hole at the tip of the drumstick. I look into the tip of mine and notice that I can see through it a little bit. Aha! I run over and grab a larger tube in the room and place it between us. I whisper into the tube to Joey and gesture him to grab it. My face is warm and encouraging. I wait. Joey smiles and picks up his side and whispers back. I raise my eyebrows and smile bigger. I whisper again. We go back and forth several times while increasing our volume, changing our sounds and deepening our connection. Joey starts to laugh. His laughter makes me giggle. I put down the tube and gaze at him lovingly. “Hi, Mary Beth,” he says. And I know he’s ready to play.

We take off toward the swing and he moves fluidly. He helps me—albeit with a slower pace—to hang up our swing, and we ride it together and have fun. He is having so much fun, Joey doesn’t know that he’s working on his gross motor development, shared problem-solving, and motor planning. He tosses bean bags at a tower, he jumps over blocks, he climbs a ladder he was terrified of climbing a few short months ago. He is really thriving. And it squeezes my heart so tightly.