By: Laura Petix, MS OTR/LEPISODE 56

Have you ever heard of therapists use terms like “top down and bottom up approach” to working with behaviors in neurodivergent children? This episode will teach you the difference between the two and help you understand the pros and cons to each approach.


Laura (01:03):
Happy New Year everyone, and welcome back to the podcast. I don’t know if you noticed, but I took a little two week hiatus unannounced just to give myself some breathing room in the last few chaos weeks of December. I hope everyone had a good holiday. I hope everyone is as regulated as possible and let’s get started. Happy 2023. It is a new month, a new year, and I am getting ready to relaunch a new cohort for the Sensory Wise Solutions Winter 2023 cohort Registration is going to open at the end of this month, but if you have been waiting to learn from me and make friends with other parents who have kids who are sensory sensitive and learn how to support your own sensory sensitive child at home, then you are going to want to get on the wait list so you don’t miss an announcement.

So head to the ot Alright, so today we are talking about something that’s really important to understand when thinking about how people, other therapists and ourselves, how we can support our neurodivergent children. But there’s a difference between two kinds of approaches. So we are talking about the difference between bottom up or top down approaches. So this particular lingo, this language is typically used among therapists in a clinical setting, and it refers to the ways that we can intervene and support or build skills in a child or a person. But of course in this context, we’re always talking about kids. So sometimes you’ll hear if you like Google, top down, bottom up approach. A lot of people use this talk in organizational company speak, how an organization is like, how the hierarchy is but this is different in a clinical setting. So for this to make sense, I really need you to visualize something for me.

So wherever you’re at, hopefully if you’re driving, don’t close your eyes, but just visualize this safely. So that picture that we always see about behavior where it’s an iceberg. So there’s the top part of the iceberg that we can all see from the surface, and typically those are the behaviors. And then underneath the surface, there’s this gigantic, huge other part of the iceberg that no one can see, but it’s a very much present and very much contributes to the iceberg itself or it contributes to the behaviors. So keep that in mind. That’s what we’re going to refer to. So the top or above the surface part of the iceberg, like I said, are the behaviors and or the tasks or activities that our kids are participating in. And below the surface, that big chunk of the iceberg are the underlying foundational skills that contribute that you need in order to have that activity or what’s contributing to a particular behavior.

So I’m going to give you lots of examples, so don’t worry, but just want to quickly insert here. I know sometimes other therapists listen to these podcasts. If you are a therapist or you are very familiar with top-down, bottom-up approach, this is a very simplified version. So you might be like, wait a second, this is missing a few things. I know in the interest of time and just to have this very digestible for the lay person who is wanting to hear this in a crash course type of way, this is very simplified. So I’m watering this down and just keep that in mind. So let’s imagine a very specific scenario like getting ready for school. I’m smiling because that is one of my our biggest struggles here at the OT Butterfly headquarters.

So you know what I’m talking about though. Everything from waking up, getting out of bed, getting dressed, eating breakfast, brushing your teeth, grabbing their lunchbox, backpack, all of that before you get out the door. So let’s just think of a very particular challenge that you’re having with your child. Oh, I don’t know. Let’s say getting dressed, pause for effect because , again, this is very, very relevant for us. Okay, so let’s say that your child is having clothing issues and that’s always causing a meltdown. Getting dressed for school. I know it’s a stretch for me to have to imagine, but if this is something that you don’t deal with, you can imagine any other part of your day that you struggle daily with your child. Try to think of it in relation to a routine something that you have enough experience of that you can imagine every step of the way.

So we’re thinking above the iceberg, what you can see on the surface, the behaviors that we’re seeing related to getting clothes on and getting ready for the morning. So I’d see above the surface things like decision fatigue, which is not being able to make a choice for breakfast, not being able to make a choice for what she’s wearing, what socks she wears, what shirt she wears, all of it. There’s also anxiety around the wrong choice. So she makes a choice and then changes her mind a bunch of times and just gets upset, beat that she made the wrong choice. Then there’s the complaints, the crying about the way that the wrists of her jacket feel against her, or the way that her handcuffs don’t touch the right part of her ankle. Any kind of irritability or just moodiness and pushback against the rest of the morning routine, which as you know, drags the rest of the whole thing out and can make for a very unpleasant way to start your day.

All of that is above the surface, the things that we see that we actually see and witness. But what is going on beneath the surface? What things and skills are prohibiting my daughter from having more adaptive or regulated behavior in the morning? What skills is she lacking that would allow her to just go with the morning routine and get dressed to get out the door? So right off the bat, I’m thinking things like obviously sensory regulation, especially around tactile processing, around interoception. Maybe there’s some executive functioning skill challenges, problem solving and executive functioning skills can contribute to emotional regulation skills and being able to be flexible and tolerate some moments of discomfort without completely losing it. All of those things that I just mentioned right now is beneath the surface, under the tip of the iceberg. So when we think about the ways that we can support a child and how we can address challenges that are coming up, there’s two categories of kinds of ways to approach them.

There’s a top down approach and there’s a bottom up approach. So going back to the getting ready for school example, top down approaches are things that only manipulate or change or address those particular times, those particular behaviors and things we see at the surface. So typically for anything we’re talking about top-down approaches involve a lot of accommodations and a lot of behavioral approaches and changes to the environment. It’s a very more of an immediate effect on the behavior. Doesn’t always mean that it’s ethical or right, and I’ll get into that later, but that’s what top-down approaches are more targeted, specific intervention or manipulation of the particular behavior or the thing you’re seeing. So some top-down approaches could be like if I just limited her choices for her or made the choice for her, which is sometimes I do that. So instead of saying, pick what shirt you wanna wear for school, do you want this shirt or that shirt?

Or you know what, I’m not even going to let her make a choice because it’s too hard. I’m going to make the choice for her. That’s an accommodation. That is a top-down approach. I could teach her something like any me mimo, which she actually does on her own sometimes that is also a top-down approach. It’s an accommodation, something that she uses to help battle combat that decision fatigue. There’s other things like using visual support. So maybe pictures of the clothes that she has available on menu of clothing options, using a visual timer to help her manage her time for getting dressed and saying, you know, only have three minutes to re-pick your shirt that you’re doing outside of the moment. I could also use top-down approaches to this challenge. So maybe I would create a weekly capsule of clothes, a weekly menu of clothes where Mondays, she always wears the pink shirt with the green pants or whatever it is that would eliminate the behavior of the decision fatigue, but it’s not targeting the underlying skill. These are top-down approaches and there’s nothing wrong with them, right? We’re going to talk about it again, but think of top-down approaches as things that are more related to behavioral supports, accommodations. So things like token charts, stickers, punishments, those are top-down approaches. So that’s what I was saying where they’re not always, doesn’t always mean that they’re good, but top-down approaches can work too. So think of them as accommodations or things to implement in the moment.

A bottom-up approach to those challenges would be everything that would address those underlying areas. So remember earlier I talked about sensory regulation, executive functioning skills, emotional regulation skills. So bottom up approach would be working on her tactile processing system. Again, this would happen outside of the moment and across several moments of time, not just a one time thing. Also, working on her emotional regulation skills, again, outside of the moment, building up her executive functioning skills and problem solving skills, again, outside of the moment. So are you seeing the pattern here? Bottom up approaches target more of the underlying skills gaps that our kids don’t have or that they need help with. And the bottom up approaches to help build those skills may take a long time to develop, but they can eventually help avoid the main iceberg like problem or behavior.

So again, top down approaches are usually things like accommodations and can have a quicker fix. Again, I’m using quotes around quicker and fix, because I typically don’t like using that to describe supporting a neurodivergent child. It doesn’t. But just to get the point across. Again, top down approaches, they don’t really build many skills and it doesn’t really have a widespread or sustainable effect, but they work, they work, they work. I will stress that I use a lot. I will say most of my stuff that I work on with Liliana are top down approaches in our day to day. So there’s nothing wrong with them and they’re actually what’s the most accessible and doable things for parents to do at home. Nothing wrong with them, but just keep that in mind. I have two analogies that I always use when I coach parents on the difference between top-down and bottom-up approach.

Because when I work with parents one-on-one or in my sensory wise solutions program, I’m coaching you on how to use a lot of top-down approaches, and that’s totally okay with, but I want you to understand so you can have the appropriate expectations. So I live in southern California and we have those really scary yearly wildfires. So every year, I mean around June to mid-October, anytime there’s a lot of extreme heat, but really from August to mid-October we’re on high alert for wildfires, and every year before the wildfires, we start seeing campaigns and politicians to talk about things like climate change and all of those things that we can do to avoid wildfires in a bigger effect, like affecting climate change and affecting the weather. Because when we make those changes from the ground up or quote from the bottom up, if you’re listening and you’re getting it then we’re going to have more effect on wildfires and having less chances of them.

But obviously that is a way bigger problem to solve climate change. And of course they’re not going to stop promoting that and telling us that we should be doing that, but it’s going to take a lot of time and a lot of efforts and a lot of people to create that change. So think of climate change as a bottom up approach to ending or minimizing forest fires. But a top-down approach is what we do every year, literally putting fires out with hoses and all of the stuff that the firefighters do every time they’re putting out a forest fire that is a approach, they’re just getting rid of it, but they’re going to have to keep doing that every year for every fire that pops up. Bottom up approaches would target climate change and things that would hopefully address the extreme weather patterns that we’re having to avoid more of that to avoid more of the forest fires and wildfires to begin with.

Here’s another example for you, flavor when you’re trying to flavor meat or steak. So a bottom-up approach to this would be like when you spend all that extra time following a recipe, the wine, the lemon juice, the garlic, the secret family recipe to marinating a really good juicy piece of steak, sorry to any vegans or vegetarians out there just go with this analogy for now. A bottom up approach is marinating your meat overnight or even more than a day. So it could soak up all of the sauces and the juice, and so it could be so flavorful when you throw it on the grill. You would barely even have to spend any time adding extra seasoning on top. Maybe some salt and pepper for flavor. But a top down approach would be like you didn’t marinate it but you could still make it flavorful by adding a dry rub on top, maybe salt, extra salt and pepper, some A one sauce, soy sauce, all of the sauces on top of the already cooked meat. So both approaches accomplish pretty much the same thing, but one takes more forethought and planning. The other one you can kind of do as an after or in the moment thing. I hope all of these, this is starting to make sense for you and it’s clicking. So most of the things that we’re doing in our day-to-day parenting lives, like the scripts that we tell them and the timeouts and even some of the co-regulation, the counting to three, the chore charge, the visual schedules any punishments, those are top down approaches to managing our kids’ behavior.

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Maybe sometimes when we do co-regulation strategies in the moment, it can be a little bit of a mix of top-down and bottom up. But if you do take your child to OT or speech or any therapies for their respective needs, whether spending outside of the moment times to build skills for the tasks that they need, those are more bottom up approaches. So many of you here know that one of my favorite approaches to working with parents of neurodivergent, especially sensory sensitive children, is using what I call, well, I didn’t coin this, but what I refer to as because of gene heirs what we call the just right challenge. And this is really taking a task or activity that your child is having a hard time with and breaking it down into really small, manageable little milestones. And this is a great top down approach to helping your child feel confident without having to completely avoid their triggers altogether.

And if you are here wondering what is the difference or where’s the line between accommodating and trying to get them to build skill, stay tuned because next week I’m going to be airing an episode on accommodations versus exposure. So that’ll be good for you. But so let’s take another example for kids who are picky eaters. A top down just right challenge approach is when you place a small micro portion of the food that they’re learning to explore alongside their main meal and maybe encouraging them to play with it by turning the carrot stick into lipstick. So essentially, you would have to keep doing these just right challenge top-down approaches for every new food you’d want them to try. So you would do that for carrots, you would do that for blueberries, you would do that for pasta. It’s exhausting and it feels draining, but it’s doable and it works and it does help build their confidence.

But it’s not a bottom-up approach. A bottom-up approach would be working on things like there are regulation there, touch and texture processing, maybe oral motor skills if they have a hard time chewing and that’s prohibiting them from properly enjoying the food maybe some sensory integration activities outside of mealtime. Again, the bottom up approach takes longer and you can’t see it directly affecting the task or the challenge right away. But the idea is once you improve these underlying skills, you won’t really have to work on each specific food every single time. The idea is that they’ll just be more regulated around food and be more tolerable to different foods and a variety of foods. So this is how I approach clothes. Ideally, I would be taking a bottom up approach to my daughter’s regulation around clothing but because we’re, it’s for us, it’s anxiety, it’s sensory sensitive, it’s all of that.

It’s taking a really long time for us to do that. So to get by week by week, I do all top-down approaches. I limit her choices. We get dressed before bed instead of in the morning. I help her rate the clothing on how sensitive they feel, and we work on it that way. But I have to do that for every new article of clothing that we get, rather than her just coming to it with a more regulated approach, which would be a bottom up approach and would be ideal. But hey, guess what? I’m like many of you out there. I can’t even access private OT for my own daughter. So top down approach, nothing wrong with it, just understand how it’s going to pan out and what to expect from it. So if you’re listening and you’re like, that’s great, I wanna do top-down approaches, how do I do a top-down approach?

Can you help me find a top-down approach for my child? Yes. If you have a child who is sensitive to clothes and they have a hard time wearing a variety of clothes, if they’re sensitive to food and they have a hard time trying a variety of food, if they are avoidant of loud sounds or busy environments and they’re always dysregulated around that, if they avoid hygiene tasks like taking a bath, washing their hair, brushing teeth, all of that, you can take top-down approaches to that and apply this in your daily life. And you can work with an ot. If you’re not working with an OT already, then you should definitely get on the wait list for Sensory Wise Solutions, which is my parent group and coaching program. And it comes with a course as well where you get to work with me for 16 weeks and I will teach you exactly how to apply these top-down just right challenge approaches to your house not to your house, to your child in your own house. So you can head to the ot list to get on the wait list so you don’t miss any announcements for that. You can also head to the show notes to find the link for that. Alright, I will see you next week.

Laura (21:52):
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Laura (21:57):
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Laura Petix, MS OTR/L

I’m an enneagram 6, so my brain is constantly moving. My OT lenses never turn off and I can’t “un-see” the sensory and other developmental skills that go in to literally every activity. I love taking what I see and breaking it down into simple terms so parents can understand what goes into their child’s behavior and skills.

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