When a child struggles with peer interactions, meltdowns, or learning challenges, it’s easy to focus on fixing the surface-level symptoms. But what if the real issue is deeper?
I’m Vicky Poston Roy, speech-language pathologist and co-owner of Dynamic Therapy Specialists in Baton Rouge, LA. One of the things I talk about often with parents (especially when we’re looking at intervention planning) is the difference between top-down and bottom-up approaches in pediatric therapy.
If your child has more than one area of concern, you might be wondering: Where do we start? What should we prioritize? That’s where this conversation becomes incredibly important.
What We Mean by a “Top-Down” vs. a “Bottom Up” Approach
Let’s say a parent comes in—and this happens a lot—and they tell us their child is struggling with peer interactions. Maybe they’re looking for a peer group or help with social skills. One of the things we’re going to talk about in that situation is the difference between top-down and bottom-up approaches.
A top-down approach looks at the symptoms and addresses those directly. For example: My child has a hard time with peers, so we join a social skills group. We teach the child how to initiate peer interactions, to say their name and ask another child if they want to play. These are language-based strategies aimed at teaching the skill that appears to be missing.
That can be helpful, but it’s not the whole picture. A different way of thinking is recognizing that most symptoms are coming from somewhere else. And so we also want to think about the bottom-up approach, which asks, “why is this happening in the first place? Why is the child having a difficult time with social interactions? We want to look at things from the bottom up.
These Approaches Have to Do with Brain Function
When I say top-down and bottom-up, I literally mean different parts of the brain. The top part is responsible for things like social interaction, problem-solving, and flexible thinking. The bottom part (especially the brainstem) handles automatic functions like balance, temperature regulation, and sensory processing.
Is it doing that successfully? Is the brainstem doing things automatically? Because when the brainstem is not able to do things automatically, we’ll get into things that look like a developmental difficulty.
An Example of How Brain Function Can Affect Social Skills
For example, let’s say I’m not feeling well. I’m hot, I’m kind of feeling dizzy. I’m not going to want to be very social because the things that my brain typically handles on its own, I’m having to actually think about. My temperature regulation is off, my balance is off because I’m feeling a little bit dizzy. Maybe my skin is a little sensitive, so tags are bothering me.
In those types of situations, not wanting to be social or saying something inappropriate might be the symptoms that something needs to be handled. But really, the cause is that my brain is busy doing other things. It’s having a difficult time with temperature regulation, sensory processing, balance, and so on.
This makes it look like I’m antisocial or have an emotional dysregulation problem. But when we look at this from the bottom-up, we can see that the dysregulation itself is a symptom. Something is going on that’s making these systems have to work harder.
More on How the Brain Functions
The brain always prioritizes protection and survival, meaning your heartbeat, your breathing, your temperature control, all of these things. Balance is one of the things the brain prioritizes. The ability to think (by which we mean high level thinking, peer interactions, back and forth, flexible thinking) is something that you can access when your entire system is functioning properly.
A bottom-up approach is going to consider the foundations that support higher level development, whereas a top-down approach is going to look at observable symptoms and work to eliminate or to put them into place.
For example, if you aren’t reading, a top-down approach would say let’s teach reading skills. A bottom-up approach would say, let’s find out why you aren’t reading. Let me look at how your reflexes are working. Let me see how your eyes are working together. Is the reason that you’re not reading because you have a difficult time with the skill of reading, and so therefore you just need certain strategies to practice? Or is it that an underlying cause is affecting your ability to read, in which case it’s a symptom?
Our Approach at Dynamic Therapy Specialists
When you come in for an evaluation, we’re not going to base our interventions on your symptoms alone. We’re first going to rule out contributing factors to identify whether or not there are things that we can remediate that will lead to development versus just eliminating a problem.
If a child is demonstrating behaviors like emotional meltdowns, difficulties with attention, or social challenges, we’re not just trying to stop the behavior. We want to understand where it’s coming from. Is it a regulation issue? A reflex that hasn’t integrated yet? A sensory system that’s overloaded?
Once we have all those answers, we’ll know which approach will help your child better. We may need to take a bottom-up approach to understand the underlying causes and develop remediation strategies. Or we may need to take a top-down approach to target the symptoms more directly and develop compensation strategies.
Reach Out to Dynamic Therapy Specialists for More Information
At Dynamic Therapy Specialists, we’ll work with you to build a plan that supports your child from the inside out. If your child is struggling and you’re not sure where to begin, we’d love to help you figure it out. Call us at (225) 767-5032 to schedule an evaluation.