Michelle Phibbs is the owner of Willow Integrated Therapy in Ann Arbor, Michigan. We had the pleasure of interviewing her about her approach to occupational therapy in general, and more specifically, working with PDA children in her clinic. Michelle has been an occupational therapist for 16 years and has worked with all different aspects of the sensory system (including a year working as a vision therapist!), both in private clinics and the public education system.
Michelle has certifications from the STAR Institute and has also completed courses for Sensory Integration and Praxis Testing (SIPT). She opened her own clinic in July of 2019 and specializes in sensory integration, self-regulation, and feeding therapy, while taking a child-led, play-based approach to working with children.
What made you want to become an occupational therapist?
I first went to school to become a Physician’s Assistant (PA) and because I was paying my own way through college, I went with the major that best matched the degree requirements for my bachelor’s degree. At the time, I didn’t know anything about what occupational therapists did. But when I had the opportunity to learn about sensory integration – which was only about a week of the entire five years of the occupational therapy curriculum – I totally fell in love with it. When I started learning about sensory integration, I realized that what I wanted to do was to someday open my own clinic.
I’m not really sure why this dream hit me out of nowhere and stuck with me so strongly, but I think it is because when I was a child, I had to work a lot harder than other kids in my classes in order to succeed. I did well, but I think I had sensory differences, and was over-responsive to a lot of stimuli. It really spoke to me, because I realized that if we support children with their sensory issues, they don’t have to try as hard as they are in order to be successful. I wanted to get this message out there to families and kids.
How many of the children you work with do you suspect are Pathologically Demand Avoidant (PDA), Autistic?
I suspect that about 1/3 of the children I work with fit the profile. I am often the last stop for families when they have gone to other occupational therapy clinics that haven’t been a good fit for their child, which I think is the reason that many of the PDA children end up with me. For example, there are families that come to my practice after they have already tried 3-4 other clinics. These are the children who don’t respond well to typical therapy approaches or an activity-based model. These are children that I suspect are PDA -- many aren’t identified – because not a lot of people know about PDA.
From your perspective, how does working with a PDA child differ from working with a classic Autism presentation?
My approach doesn’t change depending on diagnosis, rather it is always tailored to the individual child and more of a reflection of the fact that I am continually growing as a practitioner. I take an approach that is mindful of neuroception and I prioritize maintaining a safe space for the child.
I focus on a child’s strengths, at the same time I address challenges and fill in skills that are foundational to the child’s success. I celebrate the strengths.
I am not sure exactly how to compare the PDA child with the “classic” Autistic profile, because I more focus on the individual child and what they need.
What has been the most surprising part of working with PDA children?
The biggest surprise was that by fully taking an open, flexible approach to fit the child, it helped. I didn’t think it was necessarily going to work with the PDA children. I didn’t know that when I became more open to truly following the child, that they would lead me to what they would need. For example, I always try to create a safe space, focus on relationship and trust, but for some kids, the more they resist, the more structure they need, the more “on top of it” we think we need to be. But for these PDA kids – along with using declarative language – stepping back and giving them more space actually helps.
For example, with PDA children, they like proximity, but not necessarily that you are looking at them, sitting too close, talking about things that are too intimate or personal to them. They want you there, but not too close or directive. It is sometimes hard to remember that when you take a step back, you are working at the right level of space for the PDA child.
What has been the most challenging part of working with PDA children?
The biggest challenge is to be okay that you look like you have no idea what you are doing during the occupational therapy session! You have to swallow your pride, do things in non-perfect ways and make it look like you have absolutely no plan, so as not to trigger their fight or flight response. It helps to do things in a way that makes it look like you made a mistake, so that they will coach you and actually engage in the skill you are hoping they will learn, so they can take some control and autonomy in the session.
I also have to be OK with parents observing me and possibly wondering, “What is this person doing?”, although so far, all the parents I have worked with it have appreciated it. It is a huge challenge as a professional to switch into that mode, to feel vulnerable and to put yourself out there. From the outside it might look disorganized and it may look easy, but it is actually more difficult to operate like this because you are constantly thinking every moment:
How can I take what they are interested in doing, what they are already doing, and to draw them outside of their comfort zone? How can I support them in attempting something new without realizing it or while feeling safe doing it?
This is in addition to helping them get certain amounts of movement in or to encourage work on a more functional skill that they may not be engaging in on their own, while never forcing or overdoing it. It is tough as a professional to switch to that mode. But you can never force anything or a PDA child will completely shut down.
It can also be challenging to manage the timing of their progress in a way that keeps them challenged and moving forward, while also prioritizing the relationship and never pushing them so hard that they feel unsafe. It is important to keep them well-regulated throughout the session through co-regulation, while also accomplishing the goals, which is a difficult balance.
What advice would you have to other OT’s who are working with extremely demand avoidant children?
My best advice would be to be open to shifting gears and trying new techniques than what you are used to using when working with other children. Also, it is really important to be able to co-regulate with the PDA child during your entire session. For example, it will not work if you are focused on your great ideas - you have to be willing to have the child take the lead and mold your ideas from theirs in the moment.
PDA children are highly sensitive so they will feel anything that is going on in their environment, including the energy of the occupational therapist. If anyone is dysregulated, they are going to be right there with you. I try to be really patient, slow-moving, and to always provide the space they need. Whenever I detect any type of refusal or over stimulation from the child, I stop and do my best to understand what is bothering them.
Finally, it is important to know your declarative language and to be able to get very creative in order to keep up with them. With my PDA kids, I have to keep throwing things into the mix that are novel or that they enjoy, so that they can run with it themselves. I would suggest having as many props and toys as possible, so that you can always have something a little new, which gives you the option to pull them out at random. Otherwise, you risk them saying “this is boring, I’m out of here.”
What advice for parents would you have if they are looking for an OT to work with their PDA child?
Before you start therapy, see if you can visit the space, and whether it would feel safe for your child. Speak with the therapist and see if your child could feel safe with that person. It is important to get an understanding of their approach to sensory challenges and behavior. Listen for key words that are important to you about how someone interacts with your child.
If you are seeking out treatment for sensory concerns or to improve your child’s self-regulation, check with whether the therapist has certification in this area or the lead therapist does that supervises them. Ask about how they measure and track goals to ensure they will be able to consistently report progress to you. Think about in what ways you, as a parent, will be involved with treatment and whether you would like to learn strategies to help your child at home. If this is true for you, ensure the facility can support this goal of yours. I think an intensive treatment model is important for a PDA child in which they go to therapy at least two times a week. Make sure you are able to ask questions and that you feel heard. Ensure the therapist can thoroughly see the potential of your child. If you cannot see your child improving, then they are not improving enough.
Thank you so much, Michelle!
(Photo of Cooper, 5, with Michelle Phibbs. No masks are worn because this picture was taken prior to the pandemic.)