Follow the child’s lead might be the most repeated phrase in paediatric therapy, and one of the most misunderstood. This episode takes it apart: where it came from, why Tracy would rather we followed the child’s need, and how true attunement is nothing like literally copying a child around the room. There’s plenty of clinical honesty here about getting it wrong before getting it right.
Michelle wanted to scratch a theorist’s itch: where did follow the child’s lead actually come from, and what is it really? That question opens into one of our richer conversations. Tracy shares a sticky moment with a mentor who thought OTs just trail children around the room doing no good, and how she came to reframe the principle as intersubjective attunement, holding the child’s mind, body, curiosity and developmental need in your own, rather than a literal follow. She’d rather we said follow the child’s need.
Cory brings the counter-example that stuck with him: an old video of a clinician having parents copy a child grinding on an exercise ball, which is copying, not following, because nothing more adaptive emerges. Michelle walks through assessing a tentative under-two, signalling safety through the child’s co-regulators before moving in, and the watch, hypothesise, test, watch rhythm underneath it. We get into Dan Siegel’s mwe space, Ayres and the just right challenge, and then a lovely stretch on repetitive behaviours and affordances: why a child without representational thinking might see a car as a flat thing with round things that move, and how following that perceptual curiosity, plus the visual-vestibular foundations under it, opened the door for one of Cory’s clients to start pushing and rolling a ball.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Michelle: Hello everybody. We’ve been chatting about where to go with our episodes, because we’re listening to the feedback our listeners give us. We’re also involved in our own clinics and mentoring staff, and we’re seeing people grapple with some of the underlying principles behind the treatment interventions we provide. So we thought we’d start exploring some of these principles, and the phrases that get thrown around a lot, to make sure we have a really clear and precise understanding of what they mean. If you’ve got phrases you’d like us to chew over, send them in. What I was eager to discuss today is the principle of follow the child’s lead, which we hear a lot in the approaches we use, like DIR Floortime and Ayres sensory integration.
Michelle: Being the theorist that I am, I wanted to know where this came from. Who put this phrase together, and how did it come to be in OT, and not just OT, speech use it too, and it’s across lots of multidisciplinary models. So that was my itch to scratch. How did this become such a common phrase, what is it, what is it not, and how do we make sure we’re using it with integrity and validity, in a way that’s actually helpful in assessment or intervention? We’re all eager to be precise and effective. So here we go, trying to be precise about this phrase. Cory, Trace, how does this sync up for you, this idea of follow the child’s lead?
Tracy: I was thinking about it as you were talking, about the first time I ran into a really sticky moment related to this idea. It’s a funny story. I had a mentor for a number of years when I was doing research, and this person didn’t fully understand the work we do in occupational therapy, but did a lot of training around working with kids, especially complex kids. And this person said, OTs are always just following the child’s lead, following the child around the room, and you really shouldn’t commit to that kind of therapy, because it does no good. Why would you just follow the child all the way around the room? I chuckled, and then I said, well, I don’t know exactly which therapists you’ve been watching, but I can tell you this is a very misunderstood concept that easily goes astray. The idea is never to follow the child around. The idea is that your mind is attuned to what the child is interested in, in their own internal development. It’s a very intersubjective understanding of following the child’s lead, not a literal one. And as I said that, this person paused and said, I didn’t know you were thinking about the mind and all these things, I just thought you were playing. It was a hilarious moment where I realised that to the naive observer this is a very elusive concept. And it’s one that deepens almost every day you practise, for the rest of your practice: learning how to deeply attune to the child’s system, their body, their mind, their curiosity, their actual developmental trajectory, and what it needs.
Tracy: I often change the phrase from follow the child’s lead to follow the child’s need, because I want clinicians, and parents and educators too, to tune into that level. If a child’s body is moving a lot in a way that isn’t sensory seeking, that’s telling you something, and if you tune into it you’ll get the right message and know exactly what they need. As you follow that need, you make progress so much faster, and in more authentic, richer, deeper ways, than if you contrive goals to tick off a developmental checklist. So following the lead can feel slippery and elusive, and it can look as if you’re just meandering, but you’re not. I remember feeling so confronted by that mentor, and then realising, wait a minute, back up, you’re not getting it. And as soon as I stepped into, I get it, it was cool to realise this is a principle, a foundation, worth owning.
Cory: That’s very classic of you, Tracy, making an abstract, poorly understood principle clear by refining how you define the term, so the person could understand the actual clinical skill you were using. On your question, Michelle, about where the phrase came from, I have absolutely no idea. I hear it in a lot of different spaces but I don’t know its origin. Maybe it comes from many places all around the same time, and each place thinks it came from them. But I’m keen to talk about it in terms of treatment, because I can distinctly remember watching a video, an old one thankfully, and I think the affective shock of it is the only reason my brain held onto it. This clinician was working with a child and talking to parents, saying, you’ve got to follow the child’s lead, which in this video meant she had the parents and herself copy everything the child did. The child was on top of an exercise ball, grinding his pelvis into it. So she had the parents get on top of an exercise ball and do the same movements. I remember being gobsmacked that this was being suggested as following a child’s lead. In my mind, you’re literally just copying the child, there’s no change in the behaviour, so that’s not following their lead, that’s copying them. I will copy children if it creates a more adaptive change, if it allows something to emerge, or helps me achieve synchrony that promotes connection. But if I’m just following a child around copying everything and nothing comes from it, that’s not following a need, that’s trailing them, and no wonder that other person said you’re just following them around. Early on in treatment you sometimes feel like you’re chasing a child, not getting into anything deeper. In those moments it’s about stepping back and asking, what is the need I might be missing in how this child is engaging with the world, and how is what I’m doing not meeting it? Michelle, you’ve been diving into the DIR world lately, did you have any epiphanies in this space?
Michelle: I’m doing two things that keep this front of mind. I’m working with some OTs who are getting to the next level of experience and embodiment about what this means, so I’m showing videos and pausing to say, this is the decision-making underneath what’s happening here. And I’ve been deep diving into DIR. What it’s brought to the fore for me is this backwards and forwards, in and out experience. I assessed a child last week, only young, under two. They were a bit jumpy around the room, thirty seconds with one toy then moving on, really tentative, no eye gaze at the start, skirting around me, and the whole family was there. So I thought, I’m just going to sit back, answer mum and dad’s questions, and watch. I watched all the little things: how they picked things up, how they moved away from their sibling when it got too loud, how they kept their head upright all the time. That was me making assessments and clinically reasoning what was happening for that child, understanding the gaps and the need.
Michelle: Then I got involved when they looked more positive and playful, going in to join them, some parallel play and shared attention. I copied them at the start, they banged on a thing, so I banged on a thing, to see if they’d look at me or at the object, so they knew I was in their space. Then I tried to turn-take, to see if I could have their hammer, and they moved away. So it went back into my brain: watch, move in, intervene based on the reasoning, test something, see what happens. They moved away, so I came back, gave space, watched, and thought, okay, I’ll come at it differently this time. For me there was a real active and passive component: watching and making sense, making decisions, getting involved and active, then coming back and doing it again. Making a theory, planning an action, doing it, seeing how it unfolds. If it’s positive, you keep going, that’s working, they’re more engaged, more masterful with the object, playing in more complex ways. And when it doesn’t, you come back, plan B, what’s happening now? So for me it’s both a process and a kind of in-and-outing, which I know isn’t a proper term.
Tracy: No, it is a process. You’re following the lead, but there are a few things you’re following within the lead. For all the theories, the foundation is that if the child is more regulated and engageable, following that lead is really different than if they’re more disrupted or dysregulated. So one thing we have to situate in our clinical approach is really meeting the child and holding the space, regardless of that foundation. But we’re always holding in mind, and in our felt experience, that sense of the mwe space, as Dan Siegel calls it. Regardless of whether the child is more regulated or dysregulated, the us-being-with is part of following the lead. Even if the child is hesitant or remote or unfamiliar with us, we’re respectful and aware of their edges and boundaries, their openness or worry about us. What we’re doing is looking for what is of interest, what pulls them into any level of engagement, any glimmer, any meaningful repetition of an action. And in our minds we’re suspending our clinical reasoning enough to stay wholly present and be with them. We might be watching, waiting and wondering, as the DIR language says, offering an opportunity and waiting to see what happens, or joining them.
Tracy: I want to mention this idea of copying, so we all think about it the same way. We all know that if we copy each other in a way that’s not tuned in, it feels yucky, almost creepy. So when we talk about meeting the child and following their lead and joining them, we might repeat their actions, and it can look like copying, but when we do it in this follow-the-lead way, we’re attuned to the fact that we’re creating a shared mwe space, intersubjectively sharing a moment and an experience. We’re not putting something on the child or mimicking them from a distance, because copying without that affective sharing feels off to all of us. There’s an affective connection that underpins following the lead, and it’s instrumental to the whole process. In the space of connection, we tune into what the child’s system is interested in, and we build it through being with them and participating with them. It can feel so subtle just to use all those words, let alone do it. So it’s never just following their lead, it’s deeper than that.
Cory: Michelle, what you were describing, I picked up that you were following their affective cues, particularly around safe and not safe. For whatever reason that created a withdrawal for the child, and you followed their lead around those cues, the way they removed themselves, to know that’s not where things are at for you. Then you pulled the appropriate therapist responses around, okay, I follow that, now I take in your need and create a new hypothesis about how else we might create a mwe space. And then in the assessment you’d test the new possibility for whatever skill you were looking for, since he was little, maybe shared attention or sustained reciprocity. You could’ve wondered, posturally, if I’m in his midline and reduce the praxis demand, does that change how he shows up and enjoys the interaction? You weren’t just banging the hammer hoping he’d notice. If he’s exploring a quality or affordance of something, I’d step into curiosity: I can see you’re doing that, I’m interested in it too, I’m going to bang it the same way, what do you think? I’m intentionally trying to step into the mind of the child, wondering if my interest in their experience catches their nervous system. If it does, I can be curious about the possibilities of that object with them, and they might take on some of what I’m wondering about. Or they might say, no mate, I’m not ready to do what you’re doing, I need to do what I’m doing. And then it’s, okay, I follow your need in exploring this object your way, rather than me wanting to expand it. So it’s always a wondering: what offering do I put out there that gets taken up? I’m a bit greedy about wanting change, so I’m always wondering what’s the next slightly emerging skill, and how could I offer something, in the interaction, the activity, the predictability, the novelty, the sensation, I’m coming back to my STEPPSI there, and then seeing if it’s taken up. If I offer banging it a certain way and they don’t take it up, I’m not going to say, no, we bang it like this. I don’t expect them to do it the way I’m hoping, because either they’re not ready or it wasn’t the moment for that skill to emerge. So you definitely weren’t passive, Michelle, you were very active through the whole process.
Michelle: That’s right. Every time a new family comes in to observe us, I have that idea you mentioned, Tracy, the expectation that you’re here to assess him, get on the mat with the child. But I saw him doing a wide skirt, moving away from me, so my choice was not to get engaged, it was that he needs space, and I’d try to signal safety through his co-regulators. So I engaged with his younger brother and his parents, having them engage back and forth with me, feeling safe, with him observing, so that he could think, my people think she’s all right. I actually think he was picking up those cues, that she’s reliable and trustworthy and going to be okay. Then I went to engage with him. It happened to be around the thing he was playing with, he moved away, so my next move was, maybe space is a thing for you, I’ll engage across space and not get too close. He’d moved to another item, so while he had things going on, my wondering was, how do you relate to people, how are you engaging? First it was a space dimension, then all my affective tools, my voice, did I use one or not, my face, my hand motions. I tend to be big affectively, so it was, turn yourself down, Michelle. For me it’s suspending the action while I test things out, gather information, and test again. When they’re better regulated with higher capacities, it’s a lot more fluid and you’re making those moment-to-moment decisions about what the child needs: firming up the foundation of regulation, engagement and connection, or firming up praxis. When they’ve got lower capacities, I’m watching more, moving slower, taking time.
Tracy: There’s a beautiful thing happening for clinicians where you’re ever-present with the child, even when you give space and you’re talking with the sibling or parent, you’re intentionally still anchoring yourself as an available source of regulation and curiosity, gently following how the child’s affective system responds. We keep that sense of, I want you to feel awesome and safe and regulated here, this is a good place, and I’ll be a source of that for you. We stay present and attuned to pick up the subtlest things that indicate the child’s own interest and wonder, which can be very fleeting for some of the children we work with. As soon as we meet that little person for their wholeness, asking what their nervous system is telling us, we can be fully present and available while also using our clinical mind. In that mind we’re nominating candidate opportunities, like you mentioned, Cory, with STEPPSI, here’s what I might hook onto to create a different experience together. And we’re running candidate wonderings about why development is so sticky for this kiddo: maybe they need more information about the affordances of the bangables so it turns into a richer action, or more sound quality because resonant vibration anchors them in space, or that synchrony of exchange so the social space becomes more available. So we construct mini-hypotheses across different developmental functions, wondering where the just right opportunity is. In the Ayres framework, follow the child’s need is connected to the just right challenge, because you create the opening to adaptation by tuning into where they’re at and what appeals to their wholeness. Knowing a field of thinking like the SPIRIT tool gives you a way to dance through your mind and wonder in an informed way, so your curiosity is both wholly present and clinically informed. Those two together guide you in following the child’s lead.
Cory: I was smiling because you moved right into the question I had, about how Dr Ayres thought about following, how she intended it, I didn’t even have to ask. It made me wonder about following a child’s lead in the affordance-exploration part of treatment, because this is really hard. If a child is repetitively lining up toys, or tapping or banging or shaking objects, and you don’t quite understand why that behaviour is occurring or what function it serves, you sometimes feel unsure how to support the child in that moment. We’ve talked about the affordance of an activity for a child, and it would be helpful to talk about it here, because it’s confusing, and it took me a long time to even start understanding affordances. I still don’t fully understand them, but I’m a lot further along, and it’s been incredibly helpful for my treatment.
Tracy: It’s an important one in the space of following the child’s lead, because if you just copy the child rotely, it’s often unproductive and can almost be unkind at its worst. If you have a child doing repetitive things, and we all do repetitive behaviours for different reasons, but if a child is a bit sticky on it, repeating and repeating, you want to notice what they’re deriving from it. Sometimes we have to be willing to get it wrong, and we will, when we nominate these hypotheses, and that’s okay, because it’s often more complex than it appears. The primary drivers of most early behaviours in kids are either to help themselves feel organised and support regulation, or that the information isn’t connecting in a way that builds to the next block. That’s where we think about the affordance of an object as having properties that give rise to skilful interaction. For a lot of kids with more of a perception-based issue, the perceptual qualities themselves are interesting, separate from the relationship those parts have to the object. In our brains we construct and deconstruct whole-to-part relationships all the time, but a lot of kids don’t do that easily. If you look at a vehicle with wheels, you think of it as a representational thing, a car or a train, learned through language, deferred imitation, memory and meaning. But a lot of our kids operate below representational thinking. When you look at a car, you can’t not see it as a car, but a kiddo without representational thinking may see it as a flat thing with round things on it. And that’s oddly curious, a flat thing with round things attached, a bit weird, like gravity is a property: if you let go of something it should fall, and if it floats you’d look at it forever because it’s defying an expected property. Those round things also move, which is intriguing. They might get stuck on the relationship between the flat and the round, on the fact that the wheels turn, on a shininess to one part. These perceptual qualities are loud for kids who don’t have representational thinking, genuinely interesting, and they repeat things to make sense of them in a non-linguistic, non-symbolic way. It’s a space a lot of our kids get stuck in, and there we have to follow their lead. We can’t say, just jump up to representational with me and play trains, because they’re not thinking of it as a train. They’re thinking of it as a weird flat thing with round things that move.
Cory: I can talk about treatment for this to make it tangible. He’s young, his official diagnosis is a genetic disorder, and he doesn’t have language. That helps in the sense that you can’t go super representational, although we still try. He’ll be interested in the wheels, and you’ll be talking about the bigger object he’s interacting with, not the thing he’s actually moving. He picks up the car and turns the wheels, and we go straight to the representational object, rather than, oh yeah, that moves, which is the perceptual quality he’s exploring. So I talked to his parents: there’s something in this for him. I was trying to follow his lead but feeling stuck, wondering how to help him find more adaptive capacity in his praxis, because he really doesn’t know what to do with his toys, and his mum says he doesn’t know how to play, so that’s a goal. He was stuck on the spinning component of many of his toys. I’d chatted to Tracy about it, and felt I could offer some support. I told the parents there’s something he’s interested in and trying to figure out, and helped them come back to the fact that these things move and spin, so let’s find all the toys in the house that move and spin and explore that with him. He needs to figure this out as a thing, so it can become the next thing. Until he figures out that these things move and spin, he can’t move to, oh, I could push it, a new action, and it could roll, a different affordance based on that spinning quality. So they did that, and recently he started pushing and rolling the ball to us. That was really exciting, the first time I really knew what to do with that as a developmental thing, following his lead appropriately, rather than what I’d previously done, trying to go to the representational whole object and get him to join me, when the need and lead I should have followed was that he was perceptually trying to figure out a quality of an object. I don’t always get that neat and tidy, because you can’t always work out which perceptual quality they’re exploring, but that was so helpful.
Michelle: Can I jump in? In that decision-making, we’ve all had similar cases, where they may know the new affordance is that it becomes a thing that moves on the ground in different ways, so they start pushing the car around, but they may still at times pick the object up and start rotating the spinning things again. For me, that shows that in part this wasn’t only an affordance issue, in part it’s also something they’re curious about that might be self-soothing: their eyes following the spinning thing, or their fingers tapping repetitively, the wheel might have a regulating quality for them. So it’s got two functions. Once you’ve answered the first, the affordance, it still meets their need as something of interest that might be self-regulating.
Cory: A hundred percent. There’s one thing I wanted you to unpack, Tracy. One piece is his need around the perceptual quality of spinning objects, and how I help satiate or enhance that so he can figure it out. The other piece is that it transferred across many things, the fluttering of leaves, spinning of objects, any flickering or movement. So the second piece in my mind was the sensory integration element, the visual-vestibular integration around that perception. Could you unpack that?
Tracy: It’s another level of the foundation. The foundation of affordance is perception, and the foundation of perception is sensory discrimination. One important discrimination function that comes online and solidifies in the first year of life is this visual-vestibular function: if my body’s moving and something out there is moving, I know whether I’m still and the thing is moving, or the thing is still and I’m moving. You get a stability field from the vestibular-ocular reflex integrating, and as that comes together it starts the foundation of our sense of self, and self and other, and self in the environment. It’s a very specific vestibular discrimination function. So we have a lot of kids where, as the next layer of development gets complex, maybe being upright and reaching from midline out into lateral space, that can challenge it, and anything that catches the eye or moves in the periphery starts to become a bit disintegrative. We all go through this, and you feel it at different times. Recently I had a virus and some pressure in my head, and driving, I had more of that, wait, did I stop, or is the car next to me moving, that little vertigo, vestibular function, just from the pressure. I had to pay careful attention when I stopped, take a breath and land, I am stopped. So imagine if you’re developing and you walk by a revolving door, you can’t tell what’s happening. If you walk by a fence with many slats and the light changes as you go, it catches you, and you’ll walk by it fifty times, or five thousand, to sort out what that is. If we restrict kids from the experience of sorting it, it becomes dysregulating. That curiosity, where’s the light coming from, is it the light, the fence, me, is a precursor to understanding language, representational thinking, and how the world works, and it needs to be supported. We help them, yeah, what is that, I’m going to make the shadow change, wow, what’s happening here, following the child’s lead and need in that moment, filling that knowledge bucket that comes not from cognitive knowledge but from experiential, sensory-motor, embodied curiosity about how properties work. Affordances are properties, and a lot of our kids just need to understand the basic ones: what’s shiny, what’s pickable, what’s squishable, what’s movable, what’s pushable, what my hand can do versus my fingers. All those properties of my body interact with the qualities of objects, and objects that move are deeply fascinating and hard to understand until you build a schema about them.
Cory: Amazing. I wanted to do both of those things for him, following the clues about his needs. I helped his parents come back to the perceptual qualities, enhancing that for him, giving him many opportunities to just look and experience. But I was also working on his vestibular discrimination and body-awareness functions in my sessions, because I want him to figure out where am I and where is the environment, especially in how he references across space and uses his eyes. Anytime something moves too close to him, at any speed, it doesn’t even have to be fast, it gives him a shock, because he can’t track objects coming towards him through space. So that’s where my training is really useful, and I’d do him a disservice not to address it. The parents can run with unpacking the perceptual qualities and affordances, but the vestibular piece is trickier to target, especially with individual differences in parents who can’t spin, or where you don’t want to throw a child into experiences that aren’t enjoyable to the nervous system. So I’d hold him against me, spinning, stopping, then orienting and catching, yeah, we were spinning, and bopping him against my leg with a bit of rhythm to get proprioception through the spine, here you are, we’re back, let’s reorganise around the midline, let’s go again. Michelle, any thoughts on your little one, or what might be going on in that space?
Michelle: I don’t want to deep dive into the particular child, but this concept of follow the child’s need starts from the moment they walk in the door, or even as you gather information from the family. You start getting to know them, to intimately understand what’s happening across all their domains and how it comes together, so you can share that with the people around them, so they feel felt and seen wherever they go. That’s what we want, everyone feeling felt. Then, I’m as greedy as the best of them, what’s coming up first, what’s interrupting you the most? That constant watching and hypothesising, working out where I’ll go in, where it feels right. We use the SPIRIT model to make a detailed map of the child’s individual differences, and then, based on my own differences and preferences, work out where I’ll go first. It’s the underlying principle of what we’re doing in the moment.
Cory: Following the need.
Tracy: We were following the audience’s need by doing a topic like this, and it was really fun to talk over with you. At the start we asked where it came from, and Cory, you said it came from many places. I honestly don’t really know, but I do know you read it in the Hanen literature for speech and language therapists. I’ve heard it forever in the early childhood literature, embedded in most early childhood educational philosophies. Ayres sensory integration has a particular bent on following the child’s lead, and the DIR Floortime approach, Dr Greenspan would talk about it, I think even more than Dr Wieder did. It’s central to those early infant mental health days Greenspan trained in, with the Brazelton group and others. And I really don’t know where it comes from, but I saw that Maria Montessori, who predates all of those people, made it a principle in the educational model she developed, which she developed for working with children with special needs, especially intellectual disability. So there’s a wisdom to it that probably goes way back. I find it interesting that we find it across all the disciplines, there’s a wisdom you can come to trust and rely on, but it’s informed. That’s been fun to hash out with you.
Michelle: Awesome.
And that’s a wrap on today’s episode of Spirited Conversations. We hope this sparks something for you, whether it’s a new clinical idea, a fresh perspective, or just the reminder that you are definitely not alone in this work. If this conversation resonated, we would love for you to share it with anyone on their own learning journey. You can find information about the podcast on our website, and you can join us in the courses and communities the Developmental FX team have put together at developmentalfx.org. And if you’re enjoying listening, please subscribe or leave a review, it genuinely helps more people find us. Until next time, keep the conversations spirited!