Kate Broderick and Cara Sheekey have known each other for over 20 years. They first met when Kate was working in a private practice as a new graduate Occupational Therapist. Kate was Cara’s supervisor when Cara was completing her final university placement. At this clinic, they treated a population that can be described as the bread and butter of Occupational Therapy – children with handwriting, visual motor integration, visual motor perception, dyspraxia and/or coordination difficulties. The main goal was to support the children’s ability to participate in the classroom, including table top activities.
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After graduation, Cara continued to work with this population for about 5 years. She then went to work in a sensory integration-based practice in the US for 3 years. During this time, her caseload had an increase in Autistic children. The therapy structure and approach were also very different. The US focused on sensory integration and most children accessed Occupational Therapy via school funded services. Cara worked in a private practice that serviced the local school district and also privately paying clients after school hours for early intervention.

When Cara returned to Australia, she moved to Melbourne and came across DIRFloortime. DIRFloortime is a play based, developmental approach. Over the years, Cara focussed on a DIRFloortime approach combined with sensory integration. This is now known as the STAR framework which was developed in Denver. It incorporates the sensory integration approach and the floor time parent relationship coaching approach.

Attachment Theory underpins any kind of developmental relationship-based therapy approach including DIRFloortime. While many psychologists and play therapists are familiar with it, it is not part of the Occupational Therapy university course. There are many frameworks around attachment theory and the most commonly sighted one is by Bowlby and Ainsworth. They discuss 4 types of attachment styles. It is important to note that any framework that categorises human behaviour can be limiting. The focus is to look at patterns rather than strict division into specific groups. The attachment style is also about the relationship and not a person. For example, it is ‘Kate’s attachment to someone’ not ‘Kate’s attachment’. Most children have a secure or insecure attachment style with their parent. The 4 attachment styles are:

• Secure Attachment

This is when the individual is confident that their attachment figure is available to meet their needs. For a child, this means that they have a safe base to explore the world from and can return to this base in times of distress. Looking at a parent-child relationship, this would mean the child can easily transition in and out of connections with the parent.

• Insecure Attachment – Avoidant

​This is a child that is frequently described as ‘independent’. They do not seek help in times of distress and are better at calming themselves down on their own. For this child, it is easy to move out of connections but difficult to come into a connection. For humans, the most efficient way to calm down is through connections and this includes the positive signals which helps our nervous system to feel safe and secure. Children with an avoidant attachment may find it difficult to develop connections. This attachment style sometimes arises from the attachment figure being insensitive to the child’s needs or has a hard time being emotionally available.

• Insecure Attachment – Ambivalent

This is opposite to avoidant attachment where the individual is very clingy, dependent and difficult to soothe when distressed. For this child, they have a hard time moving away to explore the world but can easily return to a connection. This tends to happen when their attachment figure in inconsistent. The child has trouble deciding when to leave because they are unsure if the adult will still be there when they return.

• Disorganised Attachment

This attachment style is quite different from the others and is uncommon. It is when things are significantly more difficult and stems from challenging situations.

It is important to know that Attachment Theory is not judgement – there is no right or wrong way. Also, attachment styles are not permanent. In order to become a secure attachment, parents do not need to be ‘perfect’! Research has shown that being attuned to the child’s needs 30-40% of the time is sufficient to create a secure attachment.

The biggest predictor to a child having a secure attachment to their parent is not directly based on the parent’s childhood. Rather, it is how the parent made sense of their own childhood. A parent does not ‘pass on’ a bad childhood. For example, there are many adults who have become very resilient despite having a traumatic childhood as they have processed and developed a coherent narrative of their experiences. In contrast, adults who have ideal childhoods could have more challenges. The best thing a parent can do to foster a secure attachment to their child is to work on and make sense of their own childhood experiences.

Being aware of Attachment Theory is important to every clinician including OTs, speechies, physios and psychologists. Regardless of the reason for referral, making observations of the parent-child interaction can help guide therapy and support the creation of a positive and safe environment. For example, it is important to ask ‘why’, when a child finds it difficult to separate from their parent in the waiting room. It is helpful to consider where the child is at in their relationship with their parent, and how this affects the way they connect to the world.

There is a vast scope of what trauma can mean. Trauma is often grouped into ‘big T’ trauma and ‘little t’ trauma. Big T trauma are the obvious situations that people talk about including violence and sexual abuse. ‘Little t’ trauma can be a child’s learning disability and their experiences around that. Whether it is ‘big T’ or ‘little T’ trauma, signs and symptoms are often observable in parent-child relationships. Children who have been in truly vulnerable situations may need to live with people other than their parents.

In attachment, trauma is talked about as, in the body, not the event that occurred. We talk about how a particular body experiences and responds to a situation. For example, something traumatic to an individual may not be for another person.

Dan Siegel’s Four S’s of attachment – be safe, seen, soothed and secure.

• Safe refers to a child feeling safe physically and emotionally. For example, feeling safe to express themselves.
• Being Seen means seeing the child as they are – emphasising with how they are feeling rather than using an adult’s perception of the situation. This includes when the child is upset and understanding how the experience is for the child.
• Being Soothed is when the child is upset and they are soothed by their adult to feel Secure.

But do note – 30-40% of responding to the child’s needs is all that it takes to create a secure attachment. So, the most important factor is repair. When an adult inevitably steps outside the 30-40% of the time being attuned to the child – which all adults will, repairing as soon as possible is important. This will make the child feel safe, seen and secure. It shows that the adult is still available and the relationship is not just about that one moment. This repair makes a significant impact on the parent-child relationship. This is very different to the mainstream parenting of the 80s where adults would not make repairs, such as acknowledging and/or apologising for when they spoke too harshly.

Take home message: connect with your child but repair it when you don’t because nobody can do it all the time. This is relevant to all families, not just those who have experienced trauma.

DIR stands for Developmental, Individual differences and Relationship

• Developmental refers to the approach being developmental which is most commonly seen in the world of Autism based treatment. Autism based treatment usually fall under Developmental or Behavioural. The developmental and behavioural approaches are both valuable and can be complementary. A developmental approach is often described as a bottom-up approach where we assess where the child is developmentally and start treatment from that point. This approach recognises that the most efficient method of development is typical development. The therapy focuses on filling in gaps or working on the next step as per the developmental sequence. This starkly contrasts a behavioural approach where therapy targets at dependent on the child’s age and the specific skills required at the time.
• The individual differences in the child’s specific profile. This includes their sensory processing, speech, language, communication, cognitive and mental health.
• Relationship refers to a parent mediated therapy approach. The therapist guides and coaches the parent’s knowledge as they do the bulk of their hours playing with their children each day.
• The floor time component comes from the expectation of daily 1:1 play time with the child for 30 – 60mins. It builds on the child’s skills through play in which the adult follows the child’s lead and interests.

The sensory integration approach is focused on by the ‘individual differences’ component. Historically, sensory integration therapy focussed intensely on sensory processing. Over time with the progression of neuroscience and understanding of relationships, sensory integration now incorporates the concept of attachment as seen in the STAR framework. It applies the strong theoretical foundation of sensory processing with more child driven therapy, as opposed to the traditional therapist mediated approach.

To find out more, contact us at SPOT Therapy Hub on spottherapyhub@gmail.com or 02 9389 3322. Also check out our podcasts and blogs on a variety of topics at www.spottherapyhub.com.au