Defining Moment Bridging a Gap A behavioral therapist becomes a PT to enhance her ability to serve children with autism. By Rebecca Kilgore, PT, DPT, BCaBA | July 2018 As a behavioral therapist, I had considerable experience working with children with autism, their parents, and other caregivers before entering Nova Southeastern University's hybrid doctor of physical therapy program. I had experience working with physical therapists (PTs), too. As a member of a multidisciplinary care team, I'd learned a lot about the importance that PTs play in improving these children's quality of life. But I also saw a missed connection there, and underused potential. In fact, co-treatments were my favorite part of my job. I enjoyed opportunities to teach and learn from PTs, occupational therapists, and speech-language pathologists. Working together, we determined how each member of the care team could best contribute to meeting each child's needs. The information we shared enhanced our own work and gave us deeper understanding of, and appreciation for, the strengths of each team member. When I decided to expand my education into an additional therapy field, friends, colleagues, and even officials at the PT schools to which I applied wondered aloud why someone with a background in psychology rooted in behavioral interventions, particularly with children with autism and Down syndrome, would choose to become a PT rather than an occupational therapist. I responded to such queries with a question of my own: "Why not try to bridge a gap, rather than simply extend a bridge that already exists?" What I meant by that was that the fields of applied behavioral analysis (ABA) and occupational therapy typically are considered to be more closely related than are ABA and physical therapy. Both disciplines aim at teaching kids how to function optimally in everyday life. Therefore, it's not particularly unusual for behavioral therapists to return to school to become occupational therapists, as well. The professions are seen as complementary segments on the same continuum. The bridge between ABA and physical therapy, however, is less recognized or understood. Often, those who work with children with developmental delays such as autism think narrowly of physical therapy as "sports rehab"—resulting in its underuse as a developmental tool. But what I'd sensed from working with PTs was that, by combining my training as a behavioral therapist with new skills as a PT, I could make a difference in kids' lives that I could not make as a behavioral therapist alone—or even as a behavioral therapist and occupational therapist. By becoming a PT, I reasoned, I also could help others see the benefits of such synergy. I continued to work full-time as a behavioral therapist while I was in PT school. This experience only deepened my conviction that there was much to be gained for children with autism by bridging the gap between behavioral therapy and physical therapy. As I learned more about movement and the human body system, I began adding in functional behavioral goals for the patients with whom I worked. I also started helping my fellow behavioral therapists better focus their goals toward enhancing their patients' physical independence, in addition to addressing behavioral improvement. Since becoming a PT last year, I've continued to address the gaps that I see between the 2 therapy disciplines. Why, for example, is a teenager with autism having a tantrum? What caused it? Are gross motor skills being examined? That's where my training as a PT comes in. If, for example, a parent or caregiver consistently holds a child's hand to keep him or her from "eloping"—running away—that child may not, as a result, develop the balance skills that he or she will need in later years (after the elopement behavior has ended) to safely and independently navigate through life. That individual—by now a teenager—may remain dependent on a caregiver for simple mobility. This, in turn, would limit the teen's ability to interact with peers, adversely affecting the development of social skills—the very thing that behavioral therapists and occupational therapists often are looking to target with their treatments. Now that I'm a PT, I'm helping other PTs tease out whether adherence and behavioral issues are at play in given situations, or whether physical deficits may be the culprit. Conversely, I'm helping other behavioral therapists make distinctions among sensory, compliance, skill, and physical factors that may be slowing a child's progress. My roles as both a behavioral therapist and a PT have enhanced my effectiveness in making connections and engaging with other care team members and caregivers in ways that greatly benefit patients. The case of 1 child in particular perfectly illustrates this. This preteen's presenting behaviors included spitting and physical aggression, and physical presentation included low muscle tone, decreased strength, and no notable ability to make functional movements independently and safely. The child had little to no communication skills, nor interest in socialization and play. Where to start? Conferring with this young patient's speech therapist was extremely helpful. Augmentative communication is an alternative form of interaction for individuals who are nonverbal and cannot use sign language. This patient's augmentative communication device was an iPad Mini that was configured with an app with picture icons corresponding to commands, such as "I want to play ball." Working together, the speech therapist and I matched icons to physical therapy-specific toys and equipment that promoted motor skills development. In pediatric physical therapy, kids—whether or not they have developmental delays—care more about being able to use a toy or participate in some other stimulatory behavior than they do about whether they walk a little differently from other children, or whether it's difficult for them to reach forward or to the side without taking a step and perhaps falling. While our job as PTs with young patients is to recognize their issues with functional mobility and help progress them toward safe independence, it's also important that we make the effort fun. And what's going to be the most fun—and therefore motivating—for pediatric patients is being able to do what they most want to do at that moment. In that regard, I constantly spoke with caregivers and others to see what activities would be most motivating and fun for my young patient to do on a particular day. Over time, as the patient's ambulation and environmental interaction improved, requests for withheld snacks yielded progressively to requests to walk, use the playground, and play a game of chase with certain requested friends. Eventually, this patient independently met higher-level behavior, speech, and occupational therapy goals thanks to the physical foundation built through physical therapy. By marrying my 2 disciplines—behavioral therapy and physical therapy—I'm weeding through my patients' challenging behaviors and addressing their underlying physical issues. It's very rewarding work. It's also a gratifying reminder to all PTs and physical therapist assistants that by building that physical foundation they're playing a vital role in enhancing these kids' ability to more fully experience the world around them. Rebecca Kilgore, PT, DPT, BCaBA, is a physical therapist and a board-certified assistant behavior analyst at Great Stride Rehabilitation, a pediatric rehabilitation center in Jacksonville, Florida.