Praxis is how we generate brand-new skilfulness: the first kick, the first climb, the first time the body works out something it has never done. This episode follows a vibrant six-year-old through the praxis process, ideation, planning, execution and monitoring, and lands on the hardest clinical question of all: when do you let joyful exploration run, and when do you step in to help it become skill?
Michelle brings a composite of a delightful six-year-old boy: full of ideas, very social, and newly mobile after the postural work we talked about last episode. Now that his body can carry him into play, a different picture emerges. He is fast to have ideas but quick to abandon them, his sequencing and timing are out, his movements are ballistic rather than graded, and he changes the rules rather than monitoring and adjusting. We use Tracy’s praxis roadmap to sort his presentation into ideation, planning, execution and monitoring.
From there we get into what praxis actually is from an Ayres perspective, the sensory discrimination foundation underneath it, and why clumsiness is never just clumsiness. The heart of the episode is a story of him discovering a ball with his feet for the first time, pure joyful exploration with no mastery yet, and the question it raises: is this the emergent play that has to come first, or the moment to scaffold a little precision? We talk about following the child’s lead, building sequence through imitation and his own ’do it again’, and infusing discriminative precision without tipping the playfulness away from him.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Cory: Hello, welcome everybody. Episode three. We are hoping to dive a little into praxis today after our discussion about posture. Last episode, we all just went, oh, can we please talk about praxis. Welcome Tracy, we love having you.
Tracy: Good to see you too. I get to see these lovely ladies every week and I love it.
Cory: This time Michelle did all the work of pulling together a composite case so we could talk about praxis in a tangible way, and hopefully give everyone listening a better sense of this concept, which even now I am still trying to wrap my head around, because it is really complex. A side note: Michelle and I both brought our copies of Sensory Integration and the Child, Jean Ayres’ original book, today, just in the spirit of wanting to feel connected to Dr Ayres. I will hand over to you, Michelle.
Michelle: Thanks, Cory. Last episode, when we were talking about posture, a couple of kids kept coming to mind, because they initially came to us and the biggest challenge was posture. They had praxis issues too, but posture was where we needed to start. As we progressed through treatment, this little kiddo now has enough stability and bilateral coordination and interest in playing really physically that he is moving around a lot more. His postural challenges have not resolved, but he is now really in the room and playing with objects with a vibrancy he did not have before, because posture did not really allow him to. He was much more passive. Tracy, did you want to say anything about praxis before we intro the concept?
Tracy: Sure. In the course of this podcast, and for all of us as clinicians, one of the things that is so beautiful and interesting is how these issues connect to each other. One of the journeys we all go on to refine our treatment is to disentangle those connected dots, sort out the bits and the parts, and then put them back together. This idea of integration requires us to look at the big picture. I love the energy you describe him using, that he wants to play and engage and accomplish and participate and do all the things of childhood, and yet the things that are tricky for him we can zoom into, the bits and the parts. It is very common that we dance across these topics, because kids do not just live in one area of difficulty. This guy had some difficulties with posture early on, and now you are seeing more around praxis.
Tracy: When we say the word praxis in our Ayres sensory integrative frame of reference, praxis is related to the capacity all of us have to generate novel skilfulness. So what is that? Anything we have never done before, whether that is kicking a ball, moving against gravity, using our hands skilfully as tools, or using our social selves in interaction smoothly. All of those things, the first time we do them, are novel, and that novelty requires so much neural resource, pulling from every aspect of our sensory, affective and motor processing and our cognitive and language processing. So this concept of praxis is really big. Throughout this discussion we will refer back to a visual that gives us a roadmap around what praxis is and all its bits and parts. We might not talk about everything on that map, but from an Ayres perspective, Dr Ayres did two critical things I want to highlight. The first is that there is a sensory discrimination foundation to our ability to praxis. The second is that praxis works through a process of ideation, planning and execution, and then we monitor our performance across those elements. In the motor learning and dynamic systems theories we use four parts: ideation, planning, execution and monitoring. Dr Ayres wrote about the three core parts of that.
Michelle: They align, Tracy. Those theories align, they just have a fourth.
Tracy: They absolutely align, and those are the theories we will draw from for our evidence base, which creates the structure of how we might approach intervention.
Cory: I am getting really excited, because both Michelle and I have signed up for a neurodevelopmental treatment module, which is fun but also pushing our knowledge. I bought the Motor Control textbook and read chapter one, so when you were talking about the dynamic systems model, I could actually picture it. When you brought it up in the first episode I thought, I did not learn that at university and could not conceive of what you were talking about. So this is exciting.
Tracy: That is great. Let us hear about this little wonder you have in mind and proceed from there. When we can picture it, Cory, whether it is a concept like dynamic systems or ideation, or a child, that deepens our clinical reasoning, because we have to land it in what we can see and touch and make tangible. We hope this conversation does that for people, that it lets you question and wonder, well, what is praxis? So let us learn about praxis from the lens of this kiddo.
Michelle: The little one I have put together is six years, nine months. I get a smile and sit upright and get giggly even thinking about him. He is delightful, full of energy, with a big smiley face. He is really clever, very social, has lots of ideas and is really eager to play. When I first started seeing him he had a lot more rigidity, the classic picture: because of his postural challenges he would sit and talk a lot and direct play, and he wanted a plan that we would sit and negotiate at the start. At home, mum and dad delight in him for the same reasons, but they also say, these are my words not theirs, that he is kind of hard work, because he lacks organisational skills. He does not get himself together in the morning. He is only six, but he is not dressing and cleaning his teeth and coming out to get his lunchbox for school, and with other children to manage, they feel they have to coach him through each step of the early-morning routine, which they thought they might not need to do anymore. He gets rigid after school, so if there is a little change of plan, like picking something up on the way, he gets really emotionally dysregulated, has a big meltdown and just wants to go home. Part of that is being tired and having had enough, but there is also this sense of rigidity and predictability he clings to. He has siblings, and he is a source of quite a few fights, because he has lots of ideas and rules and wants things his way, and gets frustrated and cries or wrecks things if it does not go his way. I do not really see that in the clinic so much. So that is my picture of a really vibrant boy. When I think about him in the clinic, I will use your praxis process image to guide my thinking about his presentation in more detail.
Michelle: Starting with ideation, I think he looks much stronger in this area. I have not done the string tasks from Teresa May-Benson, but he generates lots of ideas, with little objects right through to schemas for play. He has great initiation. If anything he is too fast, too on the ready to dive into things, and that is what I think causes errors: having the idea, but not pausing before the motor action. On the simple test of gestural praxis he is okay, but he lacks some precision in the location of his body, tied with the tactile system, as what I ask him to do increases in complexity. The second component is planning, and I think he is really restricted in sequencing, right from his movement actions through to the number of tasks that make up complex activities like getting dressed. We see it in play and at home, but also in clinical observations like sequential finger touching, alternating forearm rotation, copying clapping patterns and skipping. He is just not getting the sequence of the movements right, right through to adding the tasks. The third component is execution. Motorically this is really restricting him too. In observations like finger-to-nose and sequential finger touching, and in play like drumming and swinging, his timing and rhythmicity are really out. His movements are much more ballistic and jerky rather than smooth and controlled. He is also not grading force well, he tends to be much too hard, so adding that to the sequencing, we see ballistic movements that lack precision and fluidity. Body scheme and body awareness in space is improving but still emerging. In a little section of the clinic he looks contained and moves more precisely and is aware of his body in relation to objects, me and the space, but when we move to the whole gym he loses that and bumps into things, stumbles over mats. With simple feedback he is much better than with the complex feedforward required to do things like kicking a moving ball. His bilateral integration is really reduced, with left and right not discerned or working cooperatively well, and his upper and lower limbs, he is really dominant in the upper limb. So when running, or walking up a ramp, you see him trying to climb up with his upper limb without much flexion and activation through his feet and toes. Lastly is monitoring. In more sedentary, cognitive tasks this is a real strength, he can problem-solve quite well with my assistance. But once he is in action and the demands are more taxing, the monitoring regresses and he looks much more reactive to the environment than purposefully moving and monitoring his progress. He has an adaptive strategy of changing the rules, which is a source of great frustration for everybody, because instead of going back and adjusting, he just makes the rules different to suit his imperfect action. I have not done a formal assessment recently, these are just my observations through play.
Cory: I was thinking about this the other day. Sometimes in a session I look at a kid and think, something about that is not coming together, but I am not always sure how to pick out the piece that is not. I know praxis falls into these categories, ideation, the plan the brain puts together in the moment, then executing it, and then in dynamic systems theory evaluating whether it worked. But sometimes I am not sure how to figure out which element is not coming together, which can be tricky. So my genuine question is, how do we best observe or even assess praxis if you do not have the SIPT or are not SIPT-trained? What are some good ways to start finding out about praxis for a child, apart from just, they look clumsy?
Tracy: It is really broad, but interesting. I want to talk about assessment, but first about this word clumsy. Before there was ever a description of dyspraxia from an Ayres perspective, or the lens of developmental coordination disorder, Dr Gubbay, writing back in the 1960s, talked about the clumsy child syndrome. Dr Ayres took that notion of seeing kids struggle with basic coordination, things that should come easily, smoothly, accurately and fluidly, and recognised that when those qualities are missing there is often an underlying reason. So whenever we hear about a child who struggles with coordination or clumsiness, it makes us wonder why, because on many levels, as human beings and as animals on this planet, we are meant to be movers, smooth operators, efficient.
Michelle: For our survival, Tracy. If we were falling over when the lion was coming for us.
Cory: No more Michelle, goodbye Michelle.
Tracy: Or distracted when the lion was coming. That is exactly right. And not only are we meant to be movers so we are efficient and fluid, but so we can creatively engage with what we encounter. If we come across something climbable, we want to climb it. If it is pick-up-able, we want to pick it up. If it is placeable, we want to finesse that. We are driven to use what we can do with the thing out there. So there is an interaction between our body, the affordance we bring to the action, and the bits out there in the environment. Children with sensory integrative processing issues struggle with anti-gravity control and those basic actions. What is it to be a kicker if it is hard to pick up one foot and move it separately from the other? What happens if you understand that throwing means from here to there, so you get space, but if space is confusing you might not organise it, so the ball is supposed to go up, but up means all the way to the stars instead of just a little up. So we see this lack of smoothness, grading and control, often in the execution part of the formula. But sometimes it relates back, and as you talked about this little one, Michelle, you said a lot about how he struggles with sequencing, like the morning dressing routine. Sequencing is part of planning, and a lot of the time when we see these difficulties it breaks down in sequencing.
Michelle: Can I jump in? There is a relationship between sequencing at different levels. I think Teresa May-Benson has this in a text of hers, the sequencing of neurons to muscles to tasks across the whole day. So difficulty sequencing tasks like getting dressed may have a relationship to him sequencing throwing a ball, watching it and then kicking it. It might extend beyond just muscles, tasks and activities across his day.
Cory: I got a little lost there. Were you saying Teresa May-Benson is linking the neural process of how the message gets sent from brain to muscle, the sequence of one neuron to the next to the muscle activating, and that relates to the ability to sequence actions of my body in the right order? If I go to walk, I cannot put both feet forward at the same time, I have to sequence one foot then the other. Even picking up a cup, I have to activate certain things before others or I miss the cup. And then if I can sequence those little actions, I can start to sequence bigger, more complex plans, even across time, like I need to get dressed before I go out to the kitchen?
Tracy: That is so spot on.
Tracy: Let us go back to assessment. There are standardised assessments to ascertain the qualities of praxis across ideation, planning and execution, but there is always an invitation to do clinical observations and to listen to stories from parents about daily life function related to each element. At the end of the day, clinical reasoning is critically important, because the numbers from any assessment will not tell you exactly what is going on in the underlying integrative process. That always takes your skilful observation, your ability to interpret the information, and your use of theory to make that interpretation and create the treatment plan. From an assessment perspective, we want to discern ideational skills. Teresa May-Benson has a couple of tools for looking at ideation. The task with string is the one I probably use most, but there are other tests in the neuropsychology literature too, generativity tasks and others. The base of that is really understanding affordances. We might do a whole episode on affordances one day, because it is an amazing topic. We want to understand the affordances of the child’s system and how they interact with objects in the world, which comes from observation: how they generate ideas, how they select schemas, how they match that to the context. So ideation itself is complicated. Then we move into planning, the sequencing bit. There is a truth to the neural process of sequencing and the daily process of sequencing, and a relationship between them, but it is not really a causal relationship. When a child struggles with sequencing like finger-thumb touching, touch your index finger, touch your middle finger, that is an underlying sequential process that is cerebellar in nature, based in somatosensory awareness, the body schema, the clear body map that gives you precision, and that is the sensory discrimination underpinning. So watching finger-thumb touching, we get the quality, rhythmicity and timing, which are motor execution parts, but we also observe that sensory discrimination underpinning of awareness. Those are things you observe both in a formal evaluation and ongoing in every session, to fine-tune what the child is struggling with and why it is so hard for them. You look at motor planning, sequential schema selection, how they transition through the sequence and the flow, then into grading, timing and execution. And then what happens when they make a mistake? A lot of the time when our kids are not very coordinated they make little errors and sometimes are not even aware of it, kicking the ball too hard or too soft without knowing that is an error or how to correct it. So your observation and your formal assessment are always partners in sorting out what is going on, then tying it back to that sensory processing underpinning, which in most cases of dyspraxia relates to sensory discrimination. Having said all that, Michelle, what does that bring up for you about what you know of this little one, and your clinical questions about treatment?
Michelle: It brings up heaps. While he has made great gains, he still presents with sensory processing difficulties, specifically proprioceptive, vestibular and tactile. Interestingly, in clinical observations of his visual function, it was his convergence and divergence that were most affected. He did have some skipping over the midline, about three out of ten times, so we saw some issues crossing midline, but I think it is the convergence and divergence impacting his spatial awareness, his ability to look close and then zoom back out to the bigger world. So spatially that is where he is at. There are still sensory processing challenges. I am also seeing this pattern of lots of ideas with not a lot of monitoring. He is an energetic boy, so I have some questions about his attention and inhibition. When he has an idea, instead of working hard to make it succeed, he flips to the next one. Generating ideas is a real strength, particularly when he was not moving around so much, but it is restricting him now, because you do not see him stick at something and try to improve it as readily as he does other things.
Cory: Does that come back to posture? You said he seems more generative with ideas when sitting, but once he is up and moving he looks a lot more impulsive. Do you feel that comes back to some of that postural stability?
Michelle: I think it is in part all of it: the postural stability and the spatial component. One example: we have done lots of work with vestibular input to improve posture, so he is used to swings and can now pump a swing on his own. We have used a smaller glider, a larger platform swing, a big glider. He can manage all of those, and I can set challenges where he has to stand on it and go sideways. When he has a little constraint, working with swings or an obstacle course, he has some containment and looks better. But there was a time a ball was in the room and he happened to roll it, then tried to jump it, then decided to kick it, and within moments he had it in the air and was trying to kick it, at one stage with two feet, then it went near the wall and bounced up the ramp, so he ran up the ramp trying to kick it up the ramp. I just watched, because, and this is the crux of what I want to ask you, Tracy, he was so joyful and internally motivated. It looked like the first time he was exploring an object with his feet, and he was running through all the opportunities like a kid in a candy store: oh, I could do this, there is a ramp, I could do that. None of them, from my perspective, was successful. He did not land it. And he did two things he does not usually do: he did not engage with me, even though he is so social and usually wants me as his play partner, so he was truly in his own little world, and he was not doing it to master it. So in some ways it was just joyful, exploratory play. My clinical questions are: yes, I need to keep working on those specific components of his sensory processing, and from a dynamic motor theory view, the need for repetition and then variation. And then the theory of play, internal motivation and the just-right challenge. My wondering is, at the moment it is not adaptive, but is he at a really early stage of having found some posture, enough spatial awareness and body scheme, that he now picks up a ball and is in a joyful, emergent stage of, ah, I could do all of these things? In my mind there is no mastery, but is that yet to come, and this is just joyful exploration? Or do we have to be really mindful, as the therapist, about how we create that refinement and mastery if it keeps looking super clumsy?
Cory: Without getting too cognitive about it, like, hey, if you want to play ball, let us play soccer, first I roll you the ball and you stop it with your foot, which is boring.
Michelle: He did not want to. He actually ignored me when I suggested that.
Cory: I go to cognitive a lot of the time when I am trying to do praxis: get in the middle of the swing, and I am tapping the middle, but they do not know where the middle of the swing is, and I am saying put your head here and your feet there, and I think, I probably should be doing something else. Sometimes you catch yourself and realise they just do not have the underlying concept of the middle.
Michelle: So you peel it back. Anyway, what do you think, Tracy?
Tracy: I love the way you are describing his attempts at playfulness, and how asynchronous development is, especially with kids who have struggled. If this little boy were not six but, say, 16 months old, his play would look joyful and robust and so interesting: look what he is doing, kicking the ball, slinging it, putting it up and down. That early affordance-based play is so clever. But by six, we think about how all of that should be strung together into logical sequences that turn into something more, and the journey to get there is that you joyfully explore.
Michelle: So he is where he is. He has stability and some mobility, and now he is joyfully exploring.
Tracy: Totally. And imitation is such an underpinning for praxis, but kids do not want to imitate if they are exploring their own ideas and affordances and interactions with objects. So if we put too many constraints on that, we can take away the joyfulness. What you want is to scaffold some level of sequence that makes interesting sense to him. In a session that is unbounded, kick it here and there and everywhere, when he starts to show curiosity, how do I make that happen again, how do I get more precise, how do I make it a you-and-me game instead of just a me game, then you start to build towards something. But if you impose it, you tip the balance of playfulness away from him and toward you, and that does not let him keep being an agent in the experience. So it is really a balance.
Michelle: Intuitively, I have not ever seen him play like that before, individually, without me. Everything has been pretty planned and with me. So this has caught me and stayed with me, because it was like he was playing differently for the first time.
Tracy: I love that. The interesting thing is that each element of praxis has its own developmental story, which is why it is so complicated to treat: you have to observe on all those levels. You want to allow him to explore and play, and you also know that with just a tiny bit more precision or goal-directedness it might sync up a little more quickly for him. So you infuse that guidance without imposing it. It is a fine line, and it is fun to try to talk about, and also hard to define.
Cory: I do find the theories behind these concepts incredibly helpful, because they help you make hypotheses about what might be going on and test them. But sometimes you have the theory and are aware of the concepts, yet still struggle to translate that into what I actually do in this moment in the session. How do I pull it into an operable thing to help shift the function? Do you have any thoughts about which way you start treating praxis?
Tracy: From an Ayres perspective, and neurologically from a dynamic systems perspective, you can start in the direction of the base, the sensory motor functions, or in the direction of the end point, the playfulness and his zesty, exuberant stuff. Really you work in both directions. In treatment planning we want to bring about discriminative precision, because we know that will synchronise things for him, and it is a missing element. So anywhere we get a chance, we infuse some of that, without taking away his playfulness. You observed that it is across these basic sensory systems that he is missing some foundational bits, so you continue to infuse opportunities to refine vestibular processing and bilaterality, which has improved but is not yet where it needs to be. In the recent Sensory Integration: Theory and Practice textbook, they talk a lot about how the somatosensory and bilateral systems are continuous in supporting praxis, and this little guy is really demonstrating that. So we think about bilaterality and the vestibular base, the body base, body awareness and body schema, refining his control around that, and his awareness of space and timing. In the treatment session, what I like to do is be present with the child, let them play, see what they are doing, and bring in those bits, not in a forced way but in a partnered, playful way. The journey we are always on is to build our playfulness in the present moment. What is tricky about these complicated, beautiful kids is that the clinical reasoning is so heady, but the treatment requires us to be present. So you do the thinking not so much in the moment, but afterwards: how could I have made that more proprioceptive, how could I add a more discriminative element in space? Maybe we take visual cues like pool noodles and put them at spots so he starts to target or aim, not requiring it, just giving boundaries and configuration and detail for him to pick up on.
Cory: It is like amping it up a bit. Instead of making it a requirement, being like, ooh, there is something over there, let us see if we could hit that, and pulling him into that drive to want to try it.
Michelle: As long as I genuinely delight in it, he is so ready to play it is, oh yeah, great idea, Michelle.
Cory: When you talk about the clinical reasoning being heady, it made me flash back to first learning the DIR model, and my final case presentation with a graph of my skill: not knowing much and feeling like I could get a flow, then learning more and feeling my flow drop way down because I was thinking so much about all the concepts, then finally letting it settle and picking the flow back up. Learning a new concept sometimes interrupted my ability to be present, because I was thinking so much, and then once it integrated into my own knowledge I could be present and pull things in, in the moment.
Tracy: What is so true is that that is development for us, and the same thing is happening for the kids in the session. If you push too hard in any one direction, you get them to feel taxed, like I am losing my play, I am losing my joy. That happens, and that is all right, and then we come back and refine. What an interesting way to jump into talking about praxis. Ayres theory is so rich, and the primary source to draw from for this. Even though there are some top-down treatment approaches we did not talk about, there really is such a good evidence base for using an Ayres approach, and her model beautifully fits the developmental needs of this little person.
Michelle: It absolutely fits, intuitively, from where he is at in these emerging play skills, and the idea of following the child’s lead, him being really active and engaged rather than passively talking down a plan. I just need to playfully set it up, think really hard out of session and construct some pieces of it so he can be more planful, and then let it roll on at the time really playfully.
Cory: It is just helpful to refine it. Tracy, I have heard you talk about the top-down approaches to praxis a lot, and they are fantastic when they are ready to be, when you need them. It makes sense that you would use a combination of things, because the brain is so complex you would never just use one. The brain is not just a cortex, so you pull all the pieces together and try to get the brain to integrate.
Michelle: And for my little kiddo, he has been living in his head, having to think play, and now his body is doing it and he is truly joyful in the motor execution, even though it is clunky. So it intuitively feels like it will help him, and I need to get to it, but it is not where I want to start with him quite yet.
Michelle: My takeaway is feeling really comfortable that I can keep working from constructive watching, following the child’s lead, allowing this little kiddo to play and explore, and being on the ready, with the process and the theory in hand, so that when I receive his invitation I am ready to add elements that support his monitoring, his posture, his spatial awareness, all those weaker elements, in just the right way that helps him feel more masterful with the activity he is choosing.
Cory: Beautiful takeaway. For me, the big thing was that I had not been exposed to this theory, or this way of viewing and treating praxis, until I met Tracy. So I would encourage people to think about who they can go to, to have these conversations about praxis, and where they can start integrating some of this into what they are already doing, to understand the possibilities in this way of treating. Go and find people you can have these conversations with. What about you, Tracy?
Tracy: For me, maybe in different words than earlier: children who struggle with coordination, kids with a clumsy profile, do not outgrow it, and they really can have an easier, more playful, more engaged level of participation in every part of their life with the right support. We know exactly what to do. Our treatment is gorgeous and fun and really effective, and the process of OT is so powerful for these kids. Having more kids who struggle with clumsiness able to access this kind of intervention is so critical. I hope it helps more kids find the care they need.
Cory: Thank you everybody for listening to our third episode. Hopefully we will see you all next time.
Michelle: See you everyone, see you Trace.
Tracy: See you, Cory. Bye.
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!