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This is Part 3 of our three podcasts featuring the Developmental, Individual differences, Relationship-based (DIR) Floortime multi-disciplinary clinic, Professional Child Development Associates in Pasadena, California. Dr. Brandt Chamberlain is a licensed psychologist and the head of Child and Family Counseling services at PCDA, and he is here to discuss the goals the clinicians address in their services to families. His team provides amazing support and parent coaching to families with children who have more complex needs by doing two-part therapy sessions including 1-to-1 parent sessions and also Floortime sessions with parent and child. He will also tell us about the Young Adults Group that focuses on self-advocacy and vocational exploration.

'DIR' Child & Family Counselling

by Affect Autism

The Goal of Child and Family Counselling

The Child and Family Counseling Department provides support for families where the primary emphasis is on relationship issues, and emotion management. Dr. Chamberlain has been with PCDA for 15 of its 25 years and thus has been able to seen some children grow up. He has the added perspective of being the father of a 32-year-old autistic son and wishes he would have known about Floortime when he was little. So much of what their department does, he continues, is so different than what our culture tells us to do as parents. They try to get away from the reward and punishment mindset.

Dr. Chamberlain prefers not to diagnose, although he can and does. He prefers to work with families. Usually there’s some tension that’s built up between parents and child and they have escalated the punishments. In this case, Dr. Chamberlain’s team helps the parents reflect with the child. They take into account the developmental capacities and help them work through a meltdown. Ideally, they want to catch the emotion before it goes over the top. Usually you can see some minor things that start to build up before you see a meltdown.

Through the back-and-forth emotional affective exchange, they want to help the child stay in the range of ‘functional distress’. Being able to stay at this point where they can handle it, but have the back-and-forth with the parent is building in a calm, emotional response. The parent is recognizing the child’s reaction, is attuning with them, and then is also interweaving the calmness with what the child is experiencing. The whole process of managing emotion gives the child a skill that they can use in other situations, and it strengthens the bond between parent and child. Using attunement and co-regulation in that way is an essential goal.

Attuning to the Family

Brandt gives an example of an 18-year-old young woman whose mother had a different idea than he did. The mother really knew how to connect with her child. The goal was for her to shower on her own and she believed her daughter would benefit from videos aimed at a young child. Dr. Chamberlain felt that she was an adult and would benefit from adult experiences, but he trusted the mother. The mother was correct. The young lady responded very well to their virtual session where they shared and discussed the videos. 

Other situations involve aggression in youth. Dr. Chamberlain gave a horrifying example of what happened to his own son in a group home that used behavioural methods. He loves Floortime because it’s the opposite. In Floortime, we have to be aware of what our emotional, affective communication is at the time that we set limits and expectations. In PCDA’s Child and Family Counseling, they work with families to enhance their communication and understanding of each other in such a way that they’re able to manage the strong emotions and difficult behaviours in a way that is emotionally meaningful, and that ultimately leads to stronger relationships in the family.

The misuse and misapplication of behavioural principles is very, very dangerous. It’s very harmful. The amount of damage that can be done to young people should not be underestimated. 

Brandt Chamberlain, PCDA Psychologist

Clientele Contexts

Dr. Chamberlain says that sometimes they’ll just do a one- or two-time consultation, and hopefully they get something valuable from them. To get deep changes, it’s about a year minimum. It’s not unusual to work with families for two to three years. They might have families who return during adolescence or when starting college. An example of another type of consultation was a case they had where a seven-year-old child had seen a very violent video. Dr. Chamberlain suggested watching it again with the parents. They could code each part of the video as being ok, getting a bit too much, and not appropriate because it’s too violent.

It is about helping the parents and child put it together, in the case where the child has already seen something so violent. Watching it with the parent to put it in a context is helpful in reducing the level of distress that the child’s feeling about it. This reminded me of David Bowie’s son, who is now a filmmaker talking about watching A Clockwork Orange with his father when he was quite young. Bowie sat with him, explained everything that was going on, and made him feel completely safe. It was a transformational experience for him. Imagine if you don’t have a context to put that in as a child. Brandt says it’s so important to reassure the child that they’re safe and loved.

Young Adults Program

PCDA’s Child and Family Counseling also runs a Young Adults Program. They are building on what they did with the Teen Club. Small groups meet and do activities and they also meet in large groups where they get to do public speaking, and interact with others who aren’t in their small groups. They meet on a week night and do activities, and meet in the community on the weekends — before Covid. The young adults have more of a focus on vocational exploration, figuring out what they want to do, who is doing this kind of work, how they got there, and what is the preparation to get there. What is important to be successful on the job?

The group members have identified jobs they’d like to do including working in an office with a computer, a nurse, a cartoonist, a baby cuddler in an NICU. There is a huge range of abilities in the group. Some are very verbal, others less so. Some are functioning at a high level of abstraction. With the virtual meetings they have found parents in the group who have worked at similar jobs in the past who have provided information about the jobs. They had a podcaster come in to talk about comic books, as one member wanted to sell comic books. One guest speaker started a YouTube channel about his interest, geography, and has over two million subscribers. Hearing about all of these possibilities has been really exciting for the group.

They also have learned about life skills. They were interested in learning how to shave so on the virtual meeting with the support of the parents, they all shared what they use to shave. Some had electric shavers, while others used manual razors. There is also friendship development where they’ve been making their own Kahoot quiz games which allows them to share their interests and enjoy social time together. They are encouraged to share phone numbers. They’ve had sessions to discuss etiquette around texting do’s and don’ts. Outside of the pandemic they have seen some of the participants travel to outings together on public transportation, or in a car if one drives (which involves a lot of consent).

They’ve also worked with people to help them make good decisions and figure out autonomy and self-direction (including conservatorship). Dr. Brandt has learned a lot from the Autistic Self Advocacy Network (ASAN). There are programs in California and other states where young adults can develop a person-centered plan to tailor services to what the person needs where they can set goals that they want. In watching so many clients grow, Dr. Brandt asserts that you can never predict where a person will go. You can’t underestimate, but you also have to be careful about setting unrealistic expectations–it’s a fine line, he says. Everything has to be individualized.

Dr. Chamberlain gave an example of one older client who loves the Wiggles. Even though it might be driving the parents crazy, let’s figure out how to use the interest to build skills. What they did was figure out when they were coming to a concert, then figure out how to get tickets, how to pay for them, how to get to the show, etc. Working through all the steps made them use this interest to build age-appropriate skills. I gave an example of a boy I know who loves Mickey Mouse. When the family brought him to Disneyworld, it was too much for him and they had to leave. He still likes Mickey though.

Working Towards Self-Advocacy and Self-Regulation

Brandt said that when he brought his son to Disneyland around age 5, his son was overly excited–so much so, that he had to spend an hour in the locker room opening and closing the locker to regulate himself before he could go enjoy the park. It’s what he needed to do before he could enjoy the rest of the day. He gave another example of his son being so overly excited about Christmas, that for a number of years, someone got bitten. One year he was so excited about a gift he got for his sister, that he had to run out of the room right after he gave his sister her gift. It was his way of self-regulating, by going to a quiet room, so nobody got bit.

Brandt says that this is what they aim to do in their programs; the core of what they do: use relationships in our life to help us manage our own feelings so we can build enriching relationships. I asked Dr. Chamberlain how they convince clients who are more resistant to recognizing behaviours like biting that aren’t malicious but due to upregulation, or other behaviours. They have used artwork in classrooms to help children express themselves.

In Head Start programs with younger children, they help the teachers understand the ‘why’ behind some of the non-compliance behaviours. They’ve not only trained the teachers, but also have consulted on individual cases. They’ve shown them how to build those interactions around a toy to look at the developmental capacities by starting with engagement moving into back-and-forth communication and how important the early capacities are to help the child regulate.

They aren’t really funded to do marriage counselling, but they can work with parents around their relationships and communication with the child, especially when one parent is using less of a relationship-based approach. Dr. Chamberlain said you have to build up a good relationship with families to gain the trust when challenging beliefs that some parents may have about this not being the way they were raised, and helping them understand that this way doesn’t undermine their authority as a parent in setting limits and boundaries

This week's PRACTICE TIP:

This week try to identify some of the signs your child exhibits before they have a meltdown, or become dysregulated. 

For example: Think about what your emotional affect was, what demands you might have been putting on your child, and how that may have been too challenging for your child, and how they struggled to express that to you.

Thank you to Dr. Brandt Chamberlain for taking the time to describe the valuable work that his department does. If you missed parts 1 and 2 of the PCDA podcasts, please go back to give them a listen! If you enjoyed and found this week’s interview useful and helpful, please do share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. Next week, it’s Canadian Thanksgiving, so stay tuned in two weeks for the next podcast!

Until next week, here’s to affecting autism through playful interactions!

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Julie Miller is a Developmental, Individual differences, Relationship-based (DIR) Occupational Therapist and the Clinical Director of Professional Child Development Associates (PCDA) in Pasadena, California where she works closely with the wonderful team dedicated to providing feeding services. As the former head of the Feeding and Nutrition Department, she shares a wealth of knowledge around some of the most complex challenges parents face with their children who struggle with eating for a variety of reasons. This is Part 2 in a 3-part series featuring services offered at this multidisciplinary DIR/Floortime clinic.

How the Feeding Program Got Started

PCDA is a nonprofit therapy clinic that is a completely DIR/Floortime-based agency that was created 25 years ago by Dr. Diane Cullinane and Mimi Winer, who really wanted a model that united all of the therapists who worked together. Julie says that she took for granted how fortunate she has been to expand her career learning and growing where the norm is a team of clinicians using the DIR Model versus other practitioners around the world who might be working in isolation. The transdisciplinary approach allows the appreciation of individual differences of the types of therapy and how it all supports families.

The Feeding program was created by looking at the needs in the community. Typically, Julie explains, feeding would be housed in a medical setting. It was sometimes hard for families who didn’t have specific medical needs to access ongoing developmental feeding support, she adds. On the initial interdisciplinary team they had a developmental pediatrician, a dieticians, occupational therapy, speech therapy, psychology, social workers, and marriage and family therapists. There’s about 20 clinicians on the team at any one time. 

The Feeding Program Process

When a family arrives they see the assessment team first, made up of a social worker, an occupational therapist, and a dietician. It was traditionally a developmental pediatrician instead of the social worker on the team. From this foundation, Julie continues, they ask families to tell the story of their feeding experience. 

They see a range of situations from an infant just released from the NICU, to a toddler labelled as a picky eater through to school-age children, young adults and some adults. The adults typically have a developmental disability that has qualified them for state funding, and are typically having trouble in their day programs around meal times.

The team is a developmental feeding program, which is different from teams addressing eating disorders. The clients have typically had some challenge around feeding since birth or early toddlerhood. It’s about an established stress around meal time. It might be about what meals look like.

The team uses the DIR Model as a guide in the assessment. Families are invited to bring preferred foods and a couple non-preferred foods. Just watching the family dynamics and the social exchange between the parents and the children tells them so much. 

They get hints about the child’s regulation around food. It might be a toddler running around the room nonstop, or a school-age child picking up the food and going to the corner by themselves to eat on their own.

They understand that it’s just one snapshot, so they also try to stay very calm and make sure the family and child are not overwhelmed. Everyone needs to feel safe. Then they look at the developmental capacities

Can the child share attention and engage while eating, can they have back-and-forth circles of communication, and can they socially reference others in the room and have a conversation about other things while they’re eating, or is that not what they’re interested in?

The team follows the child’s lead to see how they respond and react. They are looking for underlying medical conditions. They will make sure past medical records are acknowledged to support the home medical team for dysphagia (difficulty swallowing) or other eating problems. 

They’ll look at anthropomorphic measurements like height and weight to see if they’re getting enough nutrients for their muscles to develop and grow. Where there are concerns about low weight, parents will sometimes increase volumes of food which can lead to being too much in the longterm, for instance.

They’re also looking for children using food as a regulatory tool, which can sometimes happen when food is used as a token or reward, which is not a good foundation for one’s relationship with food. It’s about seeing how the person relates to food and the feeding experience.

FOODTIME

A few years ago I did a podcast with Jake Greenspan about their FOODTIME program that discussed a developmental approach way of approaching meals, getting children involved, and some strategies to support the process.

As the facilitator for the weekly parent support meeting for the Interdisciplinary Council on Development and Learning (ICDL), it’s rare a few weeks go by without a parent bringing up struggles around feeding. We tend to talk about sensory or medical reasons, so I asked Julie about these, giving a few examples of sensory issues around eating, but Julie adds that what presents as sensory can be more complicated.

Oral Motor Skills Once you look, you find that sensory skills really support your motor development. Oral motor skills can be similar to fine motor skills: you need a foundation of support in your body to be able to develop the others.

Food Allergies While all not children have food allergies, some children that are labelled as tactile sensitivity might have an allergy, Julie adds. The food feels different because it’s tingly or burning due to an allergy. If the adults in the room are saying, “You’re fine” but the internal sensation is that it is really uncomfortable, we have to respect that experience.

Concepts of Food Categories Then the Speech and Language team will explain how we conceptualize categories of food and language. O.T.s tend to categorize by texture, flavour and the visual presentation, but the SLPs will think about how the brain categorizes information. How can you know by the visual experience alone what the food will be? Is this a red ball or an apple? How do I know which is to eat, and which is to play with?

Food Presentation Also, fresh fruits and vegetables are very variable in presentation. A packaged bag of cookies or frozen chicken nuggets look the same every time, and parents learn to present the exact same way every time so it won’t get rejected. Children with limited diets tend to prefer these foods with a consistent presentation. Blueberries, on the other hand, Julie continues, can be sweet, sour, bigger, smaller, frozen, or mashed in a muffin. Their work is about having parents understand that it is different to the children.

The Interpersonal Aspects of Meals

All of this valuable information that Julie presented made me realize that we could do a collection of podcasts on this topic because we only have time to skim the surface of all of these topics! But what I hadn’t thought a lot about that is so obvious is how much of an impact the interpersonal aspects around meals can impact eating. If you have a parent demanding that a child finish their food, but the child can’t for any of these reasons, that can create trauma around meal time. On the other hand, you might have a lenient parent who allows access to all junk foods for fear of a meltdown.

I gave the example of my husband being apprehensive about going to restaurants because our son loves to talk a lot, and loudly. If my husband is constantly saying, “Shh…” is that having an impact? Or when our son was younger, he would knock down glasses of water, knock down Dada’s coffee, and even throw things across the restaurant if we didn’t catch it in advance, to my husband’s horror. All of these things can make eating a challenge in public, which can impact meal times in general.

The Foundation of Regulation and Safety

Julie reminisces on a developmental feeding conference they had that was a professional education conference for feeding. The participants kept saying that their videos didn’t look like Julie’s team’s and that the PCDA clients must be easier because their clients were upset and throwing things. The foundation of regulation and safety was not a part of many of these other programs, Julie quickly realized, as it is at PCDA using the DIR Model. It’s about that pyramid that shows that the foundation is regulation and safety before you can work up.

The feeding team will sometimes start with just regulation-based work first if the feeding issue isn’t causing immediate risks. If the child comes in and refuses to sit in a chair at the table, they’re not going to work on the child sitting at the table. Julie laughs that she’s done many years of sitting under the table, because that’s where the client has felt the safest. If they can maintain the interactive process and it’s safe, how ever that can happen, is what they’ll do. 

I asked about family expectations where parents might refuse to feed the child under the table, or that extended family members will be judgmental around that. Julie says that family members are always in the sessions and she can gauge the regulation–the responses and patterns–of the caregivers in the room too. She needs to know what about what she’s doing is uncomfortable or unacceptable in their family. They might do a lot of tasting with a variety of foods, for instance, which can lead to food waste that some families that might not be ok with that.

In the case of the boy sitting under the table, it was a step in the direction of getting the boy more comfortable in the routine of food and food exploration. It’s not a long-term solution. But the mother was on board, and said that this was the boy’s first experience with a therapist meeting him where he was at. The rest of his days were about being pulled along by therapists from one setting to another so she appreciated the change of pace that made her son feel more safe. It wasn’t even necessarily that her son was avoiding Julie, but it just felt more safe to be under the table where it was a bit dark and enclosed.

Consultations with PCDA's Feeding Team

Julie says that while they do some consulting outside of California, their licensure laws restrict them from practicing outside of California so it is tricky. They can, however, consult with the home clinicians (OT, SLP). They cannot be the person ‘treating’ the client.

During the pandemic, they’ve had to change to consulting virtually with their local clients, which has been interesting because the caregiver has had to take on more of a role to support the child rather than relying solely on the clinician.

In addition, she’s learned that many times, families hear one recommendation and think that that is the way to treat feeding. Julie cautions, however, that what works for one child is not a panacea. Every case is individualized and even within one case, it’s usually not just one thing that solves the problem.

The focus for the team is, “How do we decrease the stress and overwhelm for the child and family?” rather than just “How do we expand the diet?” It’s a process. It can take a lot of time to resolve feeding issues.

What Runs in Families

Julie says that often when a child comes in with a limited diet, there’s often someone in the family who is also a picky eater. It could be one parent, or both. Sometimes they still have a limited diet and will say that they don’t want their child to also have a limited diet. But that’s hard, Julie says. It’s expecting the child to have more of a variety than the parent models. It’s a bit of work with families around these types of issues. 

Affect Autism Member Question: Help! Meal time with my Kids is Really Challenging!

A mother asks what to do with her two sons. The younger child is very small and has a very limited diet, sometimes throwing up when they don’t eat enough, and is constantly moving around and finds it challenging to sit. The other is eating well, but tends to eat the same types of carbohydrates. 

Have your question answered on an upcoming podcast!

Become a Member or Star Member of Affect Autism.

The older child will be drawing or doing other things during meal time at the table. The mother is overwhelmed and not sure what to focus on. She’s tried many strategies including having a plate on the side for food that is not liked. She’s tried making different meals and experimenting with different foods.

Julie says that she sees this a lot: where there are multiple children with different needs and the family is trying to make everyone come together. There may be similar problems around bedtime, too, for instance. She says, though, that meal time happens a few times each day and how much the parenting experience is wrapped up in the feeding experience. A parent’s feeling of comfort and confidence can be challenged.

What stands out for Julie is the experience of vomiting of the younger child. Sometimes sensory aversions around food can trigger a gag response but usually doesn’t trigger a full vomit, so she would want that to be looked at. It is a very strong sensory response. It could also be a behaviour reason, according to some. It’s not comfortable to vomit, Julie says, so maybe there could be a medical condition of reflux, for instance. It makes her wonder if the child is getting enough volume to maintain growth, even though some small children are fine and still in the expected ranges. 

Regarding the preferred food of carbs, Julie says that a part of that is a child resonating with the feeling of fullness. They give your tummy a strong feeling of fullness and they are foods that break down in saliva a lot more easily. 

Julie’s suggestions: Start without bringing out any foods they don’t eat. Work first to see if your goal is having the two children eating together. Let them eat in a shared location, having the foods they both enjoy. If the goal is food variety and the weight gain overrides the children eating together, maybe one parent will eat with one child and the other parent will eat with the other. There’s a bit more support for each child, especially with children who have baseline regulatory challenges. Focus on regulation for both children.

Julie says to look at each child’s developmental capacities. This allows you to determine what to work on. If the child is working on regulation, the focus should be on regulation. Another factor is hunger. Hungry children can’t organize themselves well. The idea of withholding food to get them hungry enough backfires. She advises not to do that. Also, sometimes it might be too hard for some kids to sit together and need to sit alone to feel safe. We need to honour our children–especially older children.

What about Bribes?

What about enticing children to eat using rewards such as promising video games if they finish eating, I asked Julie. She says there’s a difference between saying, “Let’s finish up dinner so we can move on to something else.” and “Your reward for finishing is getting to play with your Nintendo.” Instead you’re stating a limit and using pacing as a mark for the end of meal time. Sometimes children just need that clarified expectation.

Julie offers us three great reasons not to use bribes with mealtime:

  1. What if the reward is suddenly not available, or what if it’s no longer a currency that the child wants?
  2. Using rewards really puts the adult in the lead rather than having the child be intrinsically interested in meal time and having self-control. It separates the food acceptance versus the food experience, making it more external.
  3. It puts a higher stress on the child because the child is already overwhelmed and now you’re adding stress to that child. This impacts baseline regulation, your ability to cope with sensory demands on you, and it affects digestion negatively. Instead of building sensory tolerance from that foundation of comfort, you’re flooding the child’s system by adding stress to it.
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This week's PRACTICE TIP:

This week let’s try to assess the family culture of meals in our homes. Does our child feel safe and regulated at meal times?

For example: What factors might be contributing to the child not feeling safe. What are we doing that we can change to help support the child’s regulation around meal time?

Thank you to Julie Miller for sharing her time with us to give us an overview of many aspects of the complex issues around feeding in our children. If you found it useful and helpful, please do share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. Also stay tuned for next week’s podcast, Part 3 of 3, where Dr. Brandt Chamberlain and I discuss PCDA’s Child and Family Counselling department.

Until next week, here’s to affecting autism through playful interactions!

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Juliana Ross is a Developmental, Individual differences, Relationship-based (DIR) Music Therapist and the Head of the Creative Arts Department at PCDA, Professional Child Development Associates in Pasadena, California. Today we are talking about the unique Creative Arts programs offered at PCDA, including music therapy, where they emphasize working closely with parents and creating many opportunities within their services to foster the parent-child relationship. All of their music therapists are board certified music therapists and have completed their Introduction to DIR and John Carpente’s training on orchestrating affective relationships in musical play through DIR/Floortime in music therapy with children on the autism spectrum.

Creative Arts Through Music and Drama

by Affect Autism

The Creative Arts Department

PCDA is one of the largest multi-disciplinary clinics providing DIR/Floortime services, serving almost 600 families. Over the past five years they’ve created some wonderful programs including music therapy, adapted music lessons, an adapted children’s choir called the NoteAbles, and a drama program called the Young Actors Squad that’s led by amazing clinicians and teachers who are not only certified in their fields, but who also have experience in extra curricular activities like choir or Improv. On top of that, bringing in DIR/Floortime makes it very unique.

In music therapy, they see babies right through to age 25. They’ve also worked with older adults in homes and special education classrooms K to 12. Most children are on the spectrum, but they also see children with global developmental delays and other disabilities. They try to include all children and families in all that they do. In every music therapy session, they always try to include the parents and family in the session. Although the clinicians are goal-oriented in the areas of social-emotional development, if you were to drop into a session you’d see family’s sitting on the floor with a variety of instruments just having fun playing and singing together.

The Multi-disciplinary Approach

Juliana continues that the best thing about being in a multi-disciplinary clinic is that while you’re in music therapy, you have speech therapy happening down the hall, then the occupational therapy gym or feeding sessions with an occupational therapist. Families are seen by multiple therapists in the Center. It allows for consulting together on a treatment team with the overall DIR umbrella to inform each therapist’s practice. In music, she says, you can see everything come together where you’ll see them use their new words or skills learned in O.T.

The team understands where each child is on the developmental milestones and what their individual differences are as they build relationships. Music therapy here is not a music service that stands alone. The staff have so much experience, many being there for over a decade now. As a music therapist, she figures out how music fits in to the child’s overall treatment and the significance of having music in their lives to engage them. It’s the affect and the fun for Juliana. Music therapy and affect are one and the same to her. It helps identify all ranges of emotion for children.

How you can interpret that in music is magical because you don’t need words to express them. If she plays a dissident chord, the child can feel that. If they’re struggling with trying to open a toy, for instance, she can express that frustration through music even if they can’t express that frustration with words. The child can think, “Oh, that’s what that feeling is and I can call it ‘this’ word“. Music is such a bridge for all the services the child receives, she explains.

I echoed how this idea of a multi-disciplinary approach is exactly what Engaging Autism describes and that it’s so much more convenient for autistic kids to come to one building that is familiar to see practitioners whom they have a Relationship with and who understand where they are Developmentally levels and Individual profilesand who all co-ordinate their services together in the child’s best interest for a holistic program for the family. I also commented on the music group setting where they’re not only doing music but Floortime in a small group.

Family Dynamics

Juliana says they love when families come in, including siblings, where you can see the family dynamics happening. It provides so much information on how that child interacts because these are the people the child interacts with all the time, she continues. One of the great advantages she has as a music therapist is how to lead groups. It’s not always easy to meet everyone where they’re at–especially when siblings don’t want to do something in particular–but when you’re facilitating a music group, you learn how to incorporate everyone’s ideas and create a cohesive group goal.

In terms of DIR, how do you create shared attention and engagement? You have to start with if everyone is motivated and interested, and everything builds after that. You always start with a hello song, introductions, then provide an activity for everyone to do together, incorporating movement, always looking to see if everyone’s participating. She tells the parents that their voice is the one the kids relate to the most–even if they’re not a good singer. It’s about creating shared moments together so you feel comfortable using your voice and using music together to empower them to be able to do this at home. She’s heard from parents that they put on music and dance around the living room. You should have permission to do that during the week as many times as you like, Juliana exclaims.

The Focus on Shared Joyful, Affective Interactions

I reminded the listener that music therapy is not music lessons. It’s not about teaching musical skills. It’s about creating moments of shared joy between family members through the use of music. It’s about the affective experience together. I shared how my son and I listen to PJ Masks and Mario Kart songs and he likes to replace the names of the PJ Masks characters in those songs with Mario Kart character names. He might sing off time or out of key, but we are having a joyful emotional experience together that he really enjoys as do I. This is Floortime

Using Music for Transitions

Your child doesn’t have to be interested in music to benefit from music therapy, Juliana says. Music is like a shared language that has that ability to connect us instantly. It’s multi-sensory as we listen to the same thing. The heart rates and breathing of those in drumming groups synchs together over time, according to research, so it can provide benefits beyond one-on-one therapy. You can take a song like ‘Twinkle, twinkle little star‘ and make it about going to the potty or putting on shoes which can become a transition song. At my son’s nursery school they used songs for every transition and it definitely helped my son and the kids with transitions.

Anticipation and predictability helps with engagement, too, Juliana explains because when kids know what’s coming next they can feel more prepared for that interaction. While it is a bit structured to sing a song every time you have a specific transition, you can change up the affect, she continues, or make it go faster or slower. You can be quieter to indicate a more calming experience. You can really manipulate the singing. We do this when we communicate with people all the time. We often match another’s posture or energy when we interact with them. Here, we’re following the child’s lead but in music, and take them to where we want the group to go.

Cue Reading for Parents

At the start of a session, Juliana says she might start by being energetic because of the tension the children may be feeling, but then she’ll slow it down, and maybe follow it up with a slower song. She’ll do this slowly to follow the pacing of the children who need it to be done slowly. She’ll read their affective and postural cues to meet them where they are at. Then she’ll point these kinds of thing out to the parents. “Oh, look, Mom, how he’s facing you now. Look how his shoulders are down now.” She tries to pinpoint all of these nuanced cues so the parent can be more aware to be the leader in the session for practice at home.

Adapted Music Lessons and Choir

PCDA also offers adapted music lessons. Having a child with a disability may make families feel like their child can’t join a typical choir or other musical group or art class, but adapted lessons are for children to be able to learn an instrument with a trained therapist, but in an adaptive way. Your child might be interested in the piano, but can’t sit for 30 minutes at the piano. They incorporate different strategies such as teaching rhythm using a drum while marching around the room or using a mallet to play eighth notes. It doesn’t look like your typical music lesson.

Your child might be able to play a 3- or 5-minute piece at their recital. They have no-pressure recitals where parents are allowed to be a part of the performance if required, and they have a sensory space where kids can go to if they need it. The trained music therapist tailors the lessons to the child’s individual needs. Choir also focuses on musical skills in an adapted way. Dr. Diane Cullinane was asked to put together a group of children for a performance at the Rose Bowl so they decided to start a choir.

A group of about 10 of different ages and abilities started to practice the Star-Spangled Banner. Even the non-speaking kids participated by humming along or waving the flag. It was very successful and they did it three years in a row. Many of the children were discouraged from joining other similar groups at their school or they didn’t have the individual support required. The staff realized they had to keep this alive, so out of this 4th of July celebration, the NoteAbles children’s choir was formed. It’s a performance group. They’ve been a part of the community performing at the Eclectic Music Festival, the Pasadena Playhouse Block Party, and performed at the fundraisers for PCDA.

Juliana says that if you’ve ever been a part of band or a performance, you know what a rewarding experience it can be performing for people or for your family, or for them to see you on stage and clap. Even through Telehealth they are leading the choir through the pandemic. They have been learning dance routines and have shown such growth from the start of the group. They also get a great turnout from the PCDA staff who get to see their clients in a different context. 

Drama Group

The drama group at PCDA is called The Young Actors Squad, a group of teens who named their own group. It is led by Kristen Williams who brings to the group her Improv training and her Marriage and Family Counselling background. She has an incredible way of communicating with the team. The head of Speech and Language, Anne Davis, co-leads the group who brings an amazing perspective because improv is about communicating. The group takes what a traditional improv class would provide (i.e., sketch-like comedy) but breaks it down into the more simple concept of “Yes, and…. You always have to follow what the other person says. This is a way to connect and build bridges on symbolic ideas.

The Importance of Creative Arts Offerings

Juliana says their team does a lot of fundraising and grant writing to make these programs possible. She credits Dr. Diane Cullinane for having the vision to create the clinic with all of these programs. Besides Creative Arts, they also have a feeding clinic for picky eaters, Occupational Therapy, Speech and Language Therapy, early intervention services, early intervention services, and teen club services. A child could start in the clinic and spend 18 years of life getting services in one place which forms the relationship with the agency and clinicians which builds trust for families and kids alike.

I expressed my dream of seeing a clinic like this in Toronto instead of the behaviourally-based clinics we have. Dr. Joshua Feder and I did discuss the move towards developmental approaches and PCDA is surely a fantastic example of what every city could offer: providing so many rewarding types of therapies including the creative arts services, having all disciplines housed under one DIR/Floortime umbrella in one location, and bringing in families and including families in the approach since Floortime is parent-mediated.

The Importance of Feeling Included

I commented how wonderful it is to have programs where parents and children can feel comfortable without the scrutiny of other families. Juliana said it’s their goal to make families feel welcome and included. The pandemic showed the practitioners how much they had a relationship with families and the process of listening to everyone over the computer strengthened those relationships. It’s also the perfect modality to coach since the practitioners can’t be hands-on and there. I took that opportunity to plug the DIR Home Program which is a virtual coaching program, and many DIR providers offer this service as well. 

All of the equipment was at PCDA so they had to get creative with the parents to use movement and song. It teaches the parent to be creative without needing toys. What makes parents the most exciting toy, Juliana explains, is the use of affect–the range in the use of your body and voice. It connects so well with music, she says.

This week's PRACTICE TIP:

This week try to facilitate some joyful circles of communication with your child around music. 

For example: March around the room to a beat, use something as an instrument to keep a beat, sing a song your child likes while using something as a drumstick to keep the beat, or whatever you can think of that will create opportunities for interaction and fun!

Thank you to music therapist, Juliana Ross, for sharing these incredible services that PCDA offers. If you enjoyed and found it useful and helpful, please do share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. Also stay tuned for parts 2 and 3 in the next podcasts where we’ll hear more about the variety of services offered at PCDA. Whether you’re in the area, or interested in similar services in your area, you’ll learn a lot about the variety of Floortime services available!

Until next week, here’s to affecting autism through playful interactions!