I am indebted to the family that has allowed me to share the following sequence of photos of their child’s journey and positive progress over a number of years. These photos have been screen shot from video footage taken as part of my long term case study for my DIRFloortime® studies and certification, along with some more recent photos added at the end.
I wish now, as an Occupational Therapist, to share a brief overview of my observations of this child’s progress relevant to the photo sequences that follow. I will highlight some of the key issues and/or positive changes that occurred with this child and which were needed to support his development, emotional regulation and sensory processing, and his relationships with important others in his life.
The first sequence of photos was taken at this child’s initial consultation or assessment. This little boy presented with an incredibly fragile sensory profile and although wanting to be with his mother, play and have fun with her; he was having huge challenges. He was easily overwhelmed by the sights and sounds of the world around him along with other sensory input. Despite his mother being available and working hard to woo and support him to stay with her with any given activity, he could only fleetingly stay, engage and share attention with her around the activity or experience before moving onto a different one. There were some brief warm and happy moments but there were also moments of overwhelm, despair and emotional dysregulation. The latter has not been shown in the photos.
In the second sequence of photos we can see this little boy playing with his mother and really enjoying big body play. His mother is a great player and we see her joining him around his actions and following his ideas of play that he has been able to initiate. The simple game of having a ‘ride on the pony’ gives this child the opportunity to work on his praxis or motor planning, how he is going to get up on the pony, his postural control and balance to stay on on the pony and what do I do if I fall off. He had to stay low and close to his mother during the pony ride as his postural control and balance was still developing along with his feelings of being safe and in control ‘posturally’. When he did crash off the pony it provided an opportunity to receive a body to body embrace from his mother which provided the deep pressure he was needing to help him pull together the big experience he had just been involved in and to integrate all the sensory input he had experienced.
Also in the second sequence we note the child initiated playing the ‘sleep game’ with his mother and you see his mother being playful, pretending to be asleep under the covers. The child had to plan how to uncover his mother so he could have that face to face and body to body contact that he so much enjoys and was wanting from his mother. Again another opportunity to co-regulate with his mother.
And finally in the second sequence we see the little boy having a quiet moment to chill out and co-regulate with his mother who is there waiting for him to be ready for the next interaction and play. When he is ready he initiates a simple ‘copy me’ type game where he moves his arms and legs and his mother joins him and they have a lot of fun experimenting with slow and fast movements.
Looking at the third sequence of photos we see an outdoor scene that came about by this child wanting to combine being on the big trampoline with bubbles. Here we can see positive changes from the previous sequence of photos where now his confidence with his body on an unstable surface (the trampoline), being able to remain upright and balance whilst he engages with his mother and me had all improved. He has been able to share his idea with us and he is having to shift his attention and work between his mother and me. This was a challenge when he was younger. Here he is having to synchronise information from his vestibular, auditory, visual, proprioceptive and tactile systems and in doing so respond in an adaptive way that fits the interaction and play. He was able to stay and share his attention for longer around an activity that had meaning to him. His ability to tune into what was required and relevant to the activity and interaction was getting stronger as was his ability to read our actions, gestures and body language. The world for him was getting easier. He was better able to read others and their intent, and was gaining greater understanding of his world. All of these important gains contributed to him now being more often emotionally regulated than not.
In the fourth sequence of photos we share time together around his keen interest with the letters of the alphabet. Here he was further strengthening his ability to work between his mother and me, constantly having to shift his visual and auditory attention and stay within the back and forth flow of the interaction, which he was now doing much better. This activity was one he chose and highlights the importance of the activity having meaning to the child. We see him intently tuning in to both his mother and me as he waits, listens to and looks at our gestures to gain more meaning around these letters. He then in turn responded with a word that he knew started with that letter or gave the answer to the gestural cue that I gave when I pretended to lick an ice cream or he traced over the letter with his finger using his tactile and movement systems to reinforce the kinaesthetic map for forming that letter.
After we had looked at the pile of letters he chose to change the activity and moved to another part of the room. Unfortunately, he wasn’t able, in this case, to clearly share his next idea with us. He spread all the letters out on the floor, appeared overwhelmed visually and frustrated that we couldn’t work out what he wanted and then became understandably dysregulated. The last photo in this sequence we see him with his mother and accepting her co-regulating deep pressure hug.
In the fifth sequence of photos the play starts with us all choosing and wearing a funny hat. The child then decided to climb up onto his mother’s shoulders and lounged forward over her onto the trampoline. His mother voiced her discomfort. Here I helped draw the child’s attention to ‘Poor mum are you okay?’ with mum responding with ‘Oh – my neck is sore!’
A problem had been posed to him ‘What shall we do – poor mum?’ He had to work with us to solve the problem and plan how he was going to help his mother. We see that he acknowledged his mother and my actions to help mum out before he communicated his idea ‘the doctor’s kit’ and then ventured off to find it. On his return he played out being the Doctor and attends to mum. What he was doing was playing out something he had experienced himself in real life, putting mum through all the usual checks that he would have received from his visits to the Doctor. I scaffolded and assisted him to refocus on mum’s initial problem her neck as, in becoming the Doctor, he had lost that important piece.
In the sixth sequence of photos we see another outdoor scene where the child is older. By now his ability to ideate or come up with ideas for play had expanded to involve scenarios that he may not have experienced or were imaginary. Here he had decided to go camping with his mother on the trampoline. He became the director and was relaying to me what they required for their camping adventure – a tent, blanket and some food (pancakes and honey). In this play he had to plan how to set the tent up, work out who would go in the tent first (he communicated to mum she go in first) and when mum says she needs help he excitedly helps her but does so with too much force. He was still learning about how much is enough – how much is too much. He then expands his play and suggested to mum they hide from me under the blanket with his plan being to surprise me on my return. At the end we see him squeezing honey onto their pancake to share. The whole session was devoted to playing out his idea of going camping and sharing this experience with his mother. There were no signs of emotional dysregulation or in need of co-regulatory hugs – he was calm and able to apply himself to this experience and clearly communicate his plan and ideas, and execute them to his satisfaction. This activity had a lot of meaning for him.
Following this stage and before the next sequence of photos, time spent in therapy was specifically devoted to developing this child’s postural control, balance, bilateral motor coordination and praxis for gross motor activities and these were all done with him having to work with one or two other people. We had a number of sibling sessions which proved beneficial for both siblings to experience and explore other ways they could play and support each other. With our support they had opportunities to deal with the emotions that go along with sibling rivalry, winning and losing, as well as just having a fun time together.
The seventh, eighth and ninth sequences of photos have been taken more recently and show this child older and approaching adolescence. Our focus within his therapy sessions has moved towards specific work on fine motor strength and skills, and specific skills like tying up shoelaces.