This is our first full case with a real child, a seven-year-old boy with a mixed sensory profile that refused to fit the textbook. He flinches at haircuts but seeks sharp bark underfoot, covers his ears at dogs but craves heavy metal. The episode follows Cory’s clinical reasoning across several sessions to the breakthrough: rhythm, intensity and head inversion together, and the first time he turned, looked, and spoke straight to her.
After three episodes on modulation and state, we put it to work on a real case Cory has permission to share: a seven-year-old boy with autism, level two, whose profile is a genuine puzzle.
His dad’s goals are simple and practical: sustain attention on a task, and cope at the shopping centre. His mixed state presentation and intensity seeking, alongside a need for inhibition, is exactly what makes him hard to read.
Much of this episode is about how you reason when clarity is elusive: holding a working hypothesis, recalibrating each session, and partnering with families as fellow detectives rather than downloading expertise to them. Cory and Michelle talk candidly about videotaping themselves, how confronting it is, and how it sharpens therapeutic use of self. Then the breakthrough: anchored over an exercise ball, head inverted, rocking to shared rhythm through a kazoo, the boy down-regulates through the baroreceptive reflex and, for the first time, sits up with spontaneous language directed straight at Cory. We unpack why rhythm plus intensity plus inversion was his just-right formula, why the move-away-and-return is part of the work rather than a failure, and how it opens into imitation and the DIR levels we will pick up next episode.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Michelle: Welcome to episode seven. We are here mentoring with the wonderful Tracy Stackhouse again, this is my favourite time. We are bringing you a case that will hopefully pull together what we discussed in the last two episodes, where we did a deep dive into modulation and state, and broke down sensory modulation in particular, and how it is really state-dependent. Our job is to take what we are learning and bring it to our sessions, to make a difference in the lives of the children in front of us, in the moment. So we thought it would be a great opportunity to take a case Cory has prepared and see how she is exploring state and modulation in action, across three or four sessions, and how we integrate the theory into practice. Welcome, Cory.
Cory: Hi Tracy. I am keen to get started today, I think it is going to be a good episode. We talked way back in the first episode about doing cases, and it felt like we needed to get some information out of the way first. So I am really excited, because I actually have permission to talk about our little friend today. This is a young boy I have been working with, seven years old, with a diagnosis of autism spectrum disorder, classified at level two. A couple of things in the initial phases of assessment prompted me to think about sensory modulation before I had even laid eyes on him. In his questionnaires, things like, he hates having his hair cut, or his face washed or wiped, but in the same vein he wants as little clothing as possible and to be barefoot on really intense surfaces, like sharp bark chips, to the point where sometimes his feet get cut and he does not worry about it, he seeks it out. He also has auditory sensitivities, to the point that he will almost refuse to leave home because he is worried about certain sounds, dogs barking especially was really hard. But on the opposite end, he seeks out really intense sound in the form of music, he absolutely loves heavy metal rock. Other behaviours that made me wonder about his overall ability to regulate and modulate input were the intensity of his bouncing, and the way he would hit his own body to organise himself, or that is what I would hypothesise, and his dad said he did that really frequently throughout the day. Some of the goals when we started were to sustain his attention on one task for longer, because he had a hard time staying with anything without needing a break or to move his body, constantly on the move, and to be able to go to the shopping centre and stay regulated enough through that experience, which was really tough for him. Those were the clear functional goals dad brought to the table. I thought this case would be helpful because it clearly demonstrates the modulation challenges we have been talking about, but also because it lets me explain the process of clinical reasoning for him, because it was not quick and easy. I had to be really purposeful to figure out his recipe, because especially initially I was really struggling to figure out what was going on and how to intervene.
Michelle: I am so grateful you have brought a real case, because we can get buried in textbooks, but this is why we bury into the textbooks. Thanks, Cory.
Tracy: The beauty of what we are sharing is that it is so much the real deal. Every time a clinician steps into the space with a child, we are trying to address things from a base of theoretical and therapeutic clarity, and sometimes that clarity can be elusive. The reason I have dedicated most of my career to the process of clinical reasoning is that every one of us has these questions. We can be in the moment, wondering, do I have clarity about what I should be doing here? I say that hoping it does not scare the parents or other disciplines who refer kids to us, trusting we have sound practices, and we do. But the work we do in integrated paediatric therapy is not a recipe replicable from one child to the next, it is not a formula or a checklist. All of it is based on individual differences and on learning about that child’s nervous system, as the whole of who they are. As we identify where the struggles are, the rules that live in the textbooks do not always apply, and that is why we need clinical reasoning models, because we have to be willing to be vulnerable enough to say, I am confused, I do not exactly know what is going on for this child, why does it look so different from this situation to that moment? All that variability is even more present when a child is struggling with modulation and state-related issues. When we pause and know what questions to ask, and trust a process and work through it carefully, then we come to clarity, and that clarity guides the really purposeful holding of the moment. What is true for every clinician I have met is that when you get to purposefully holding the moment, that is when change happens. That was true for this kiddo, right, Cory? It is in the clarity that you can foster adaptive responses, and without clarity any of us can struggle to get to that level of adaptation that facilitates progress.
Cory: Sometimes it is okay to get bits of clarity as you work through the reasoning, and recalibrate every time you get more information. That is how it felt in this case: each time I saw him, I had more information to unpack and figure out my hypothesis. Sometimes you are really not sure, you are trying things you think might help but seem to be missing the mark, or partly getting there but not sticking, so you are not moving him into the state or the place you want, where you can do the work on the goals. What comes up for you, Michelle?
Michelle: I am thinking about what Tracy mentioned, having parents and educators listening and hearing that we do not know it all, all the time, and I am okay with that, for multiple reasons. Some of the families we work with have very complex children, and when we are honest and say, his profile is complex, he has a few comorbidities, it is going to take a while, will you partner with me? What do you know, how do you understand him, I wonder why you think he thumps himself quite hard a number of times a day? That lets us become a team, rather than me directing the show. A number of years in now, I do not feel I need to be the boss of the show in the clinic, and I love fostering that relationship with families so we are partners in wondering. I wonder what happens if he does this, this week let us focus on rotation, or on sound, I wonder how that looks, will it impact his capacity to participate at meal times or when you go shopping? I love bringing them in to be a detective with me, sharing in the process, because the kids present vastly differently in other places and other states of arousal, so I want to know about that. I give them information so they can help solve the problem for their child.
Cory: They give you more clarity, because they give you the information you do not see in the session, the functional information that really makes a difference to what you are trying to figure out.
Michelle: And in the long term, we dip in and out of these children’s and families’ lives, but they are in it forever, so part of it is empowering them. There is this thing called modulation, this thing called state, let me tell you about it, what do you think? They share volumes, often more information than our questionnaires capture, once I explain a concept. So now I am vulnerable enough to say, particularly with these really complex kiddos, this is going to take us a while, will you join me as we try to solve the problems? It can be really positive.
Tracy: Absolutely, and I love that positive team empowerment we want to go for. Sometimes the parent comes in and the goal is, let us be able to go to the shops, a quality-of-life goal many families have, but when we design the treatment plan it can feel far away. Clinicians often ask me to help them connect the dots between the parents’ goals and what they see clinically. Our treatment process is that process of connecting the dots, and the more we partner and wonder and learn together, instead of me having expertise I download to you, the more effective it is, and the more it empowers the family to deepen their understanding and thrive. Regardless of the goal, that is what we are always going for. As the clinician, landing in that space, it feels so much better to say, we are going to sort things together, I am not just doing to you. That attitude is really what a relational model of intervention is, what an Ayres SI model of intervention is.
Cory: That resonated strongly with me, Tracy, I am not just doing to you. I never feel like that in a session, and if it starts to tip that way, it does not feel like I am allowing for adaptation, so it does not feel effective. It might be the joy and sparkle you see when you have that just-right challenge or just-right mix for the child, and they become super adaptive.
Michelle: It does not feel quite right for the kids either, like, oh, I am talking too much, or I did not get the task quite right, so we are not in the flow of it, and nor are the kids, you see them pull away, I do not want to do this anymore. The kids of all capacities know when it does not feel quite right. So Cory, you would have been bringing lots of theoretical models to this beautiful seven-year-old. One of the first things we reflect on is the profile, autism spectrum disorder, so you had that big chunk of information. What other chunk did you have in mind coming into treatment?
Cory: Before I came in, I had the information you get from the questionnaires, about function in each area of daily life, social participation, grooming, dressing, feeding, sleep, toileting, school. Sometimes autism helps me in one way, because it gives me information about what might be presenting, but then I have to go in and find out exactly how it is coming about for that child and family, because every child, no matter the diagnosis, but particularly with autism, has taught me different things, because they present in very different ways, their autism is unique to them. The second big thing that helped was chatting with his mum and dad before seeing him, which gave me a much clearer picture from the get-go. I had a working hypothesis right from then, before he even got into the clinic: that he is really heightened in his arousal and working really hard throughout the day to organise himself to function. That is where I started, not super specific, but that is where I started.
Michelle: So a state challenge: he has autism, he has a state challenge, and modulation, and particularly sensory inputs are difficult to organise for him.
Cory: And there is something he is trying to manage to do what is asked of him throughout the day.
Michelle: We also bring an Ayres Sensory Integration approach, so that is one of our approaches, and I know you have trained in DIR Floortime. Was there any other pile of knowledge you were bringing?
Cory: It is so hard to define when it is so implicit, isn’t it? Like you said, my big working theories are SI and DIR, because of the way I am trained. The other thing I always think about is the motor system and how that plays into the mix.
Tracy: Cory, when you start to treat kids and formulate that initial theory of how they are, it helps guide what you might do in the clinic. In our sessions we have to allow ourselves to hold that theory so we can put into practice the direction of organisation, the direction of regulating that nervous system. One of the things we do in the Spirit framework, which we shared in the last few episodes, is recognise that the more simple linear models of under-responding and over-responding often do not help our clinical reasoning, so we have to dive deeper and have a theory that matches the complexity. This case really helps us share that, because it is not straightforward like a linear continuum, it is more complex. You formulate your hypothesis of what is happening as the child tries to process, organise and adapt, and in your session you go forward with a notion of what you think might organise and regulate them. But because our work is so relational, it is hard to observe yourself doing it. So one thing that is super helpful is to videotape yourself and watch it later, to more deeply consider what is going on. It would be helpful to hear about both, Cory: videotaping yourself and what that is like, and then what you learned about this precious guy from observing it, and how it deepened your theory of him.
Cory: One reason I ended up videoing was that I felt I needed additional strategies to reason out what was going on. When you have a really complex kiddo in front of you, it requires so much attention and presence, you are working at every level to track, trying to be as specific and focused as possible without losing the connection to the child, and those kids demand every element of attention and connection you have. So sometimes you come in with an idea, and when that plan does not quite work the way you expected, you can feel a bit behind the eight ball, trying to regather and reorganise, because that experience was actually disorganising, but in the moment it is hard to do both. I like to film because it captures things you do not always see in the session. The number of times I have turned around to grab a toy and something happened on the film I did not see, that watching back later I could pick up, is more than I would expect. Or something I did not see even when looking right at the child, that later I could notice and go, aha, that was my moment and I missed it, and that is okay. It is super confronting the first time you film yourself, it took me a number of watches to get over the sound of my own voice. But it is in that confronting experience that I have done my most significant learning, refining what I was doing, with the option to talk about it with someone I respect who can help me in that process. It can feel embarrassing, because you bring yourself to the treatment, so you have to be vulnerable to say, I am going to film what I am doing because I think I am partway there but could get that last bit refined. Michelle, you film as well.
Michelle: I love to film. When I first started, I did not show people, nor did I need to. I realised that when you are in the flow of a relationship, totally immersed in the moment with the child, there is some entrainment. The first video I looked back on, I was talking to a nine-year-old girl who presented at a much lower level, in a really baby, sing-songy, high-prosody voice fitting for a toddler, which is kind of where she was socially and emotionally, but it was just not right. I had inadvertently slid down to her level of capacity, and it was not the right thing to do. It was wonderful to have that awareness. So now I regularly, randomly film myself, to work things out but also just to check, am I on, am I right here, what is my voice doing, am I moving too fast, am I being entrained into the impact of that child’s system, am I falling in? I do not know the technical words, but I want to hold rather than fall into it.
Tracy: Right, and that is the power of clinical reasoning, because therapeutic use of self is not always intuitive. How you inform your intuition, how you shift a basic response that may not be the most adaptive, the only way to get that is to see it, talk about it, and problem-solve it. Clinical reasoning is naming, not that there is a big problem, but that there are elements and approaches that need fine-tuning and do not always match the intuition. You are both exquisitely intuitive and so attuned to children, and yet therapeutic use of self is informed by our practices and our theory, so you do have to spend time in clinical reasoning to get that fine-tuning. That is the dedication we hope this conversation inspires, because we know the power of it, and you are demonstrating it. I feel privileged to have seen your journeys and how much growth you have achieved by being willing to film yourself and try something different.
Cory: You have these intuitions, but you almost need to refine them for every single child. Early on, things I did automatically worked for some kids but not others, so I needed the ability to readjust my therapeutic use of self, so each child had a matched partner in the work. That took a while, and I am still working on it. For this little guy, the reason I wanted to film him was to get clarity around his recipe, because I was trying some principles I had had success with. I wanted to try linear vestibular input on a swing, resistive movement in Lycra, and intensity, because he was going for intensity in many things he did to organise himself. I wanted rhythm, because the ways he was trying to give himself input were rhythmical, and he likes music, that innate drive kids have to organise their own nervous system. But every time I came at it in sessions, it seemed not quite what he needed. I would try movement on the swing and first I would lose connection, and he would get wound up into a script of his own, then throw himself off the swing and laugh and scream manically, and I thought, that is not helping you. So I had multiple sessions trying different things he was seeking out, jumping off the loft into the pillows. I was not telling him, I would just put up the swing and say, should we try it, and he would get on, and it did not quite work. Or the loft, he would jump off and start crying. It was woe to go, no modulation, no organisation. So I thought, that is it, I just need to film this, because I need to figure out how to tweak it. Luckily, the first time I filmed, he jumped on one of the exercise balls, and I had the instinct to anchor his legs, anchor him through his knees to the ground, and he threw himself backwards. We both had a kazoo, so I started to rock him with rhythm, giving rhythm with the kazoo, and he was upside down and rocking so his head kept bumping lightly into the soft mat under him. He did that for a period, it could not even have been that long, but then he sat up and had spontaneous language, directed, looking at me, directed to me, for the first time I think I have ever had in a session. I was like, oh, what just happened, that was really different, he was really connected, really organised. He did not stay in it, and I lost him for a bit, but he came back, and I caught it quick enough, because his postural system was not good enough to stay on the ball and replicate it himself, to do it again, which let me have this back-and-forth with him in a much more organised interaction. So that is why I wanted to film, and I was lucky enough to capture the moment where I thought, okay, I think I know how to organise you. But my question, Tracy, is what was going on there, what mechanism was I hitting into, how was that so helpful, because there are so many bits to it?
Tracy: Let us unpack a couple of the key bits. One is the rhythm, the rhythmicity. Throughout many sessions and in his daily life, he is showing you that rhythm is a thing he is going for. When kids have a particular quality like that, it is important to find a way to use it. But one thing about him is that rhythm gives him a sense of, here I am, and he does that over and over, but here I am is not quite enough, because he has a mixed state where he needs incredible intensity, and yet he also needs inhibition, because intensity just undoes him, and rhythm is not enough to hold it, not enough to bring it into enough inhibition. The quality of rhythm, through auditory, vestibular, vibration, tactile and proprioceptive input, has a grounding, organising quality. As you offered that to him, and I watched the video, every clinician has had the experience where, when you really on purpose find rhythm that resonates with the child’s nervous system, you start to want to repeat it and they want you to repeat it. So it becomes a shared experience, not the cold delivery of rhythm through sensation, you were doing it relationally, and through multiple channels, audition, breath, vestibular and somatosensory together. You are coupling sensation, not just using one channel, and doing it with a clear shared purpose that entrains between the two of you. The magic of that shared experience moves a child from dysregulation into the possibility of connection. So instead of him trying to regulate himself, you become a co-regulatory partner, and co-regulation is so much more powerful, it opens the possibility of engagement and reciprocity, which he is deeply seeking but does not know how to reach. The second thing is inversion. When you have a child who needs intensity but needs to downregulate and inhibit, head inversion in particular goes through the baroreceptive reflex, which really affects physiological regulation. If you felt his heart rate before inversion, it would be very fast, his respiration fast. With head inversion, the receptors in the arteries and the venous system get pressure, and that pressure says, downregulate the heart, it is going too fast, bring the rate down. It is like a physiological switch, sending a different signal to his nervous system, instead of being on and going and fast, I need to slow down. And that slower space with intensity, the coupling of inhibition and intensity, is his just-right formula. When you hit that, he has an adaptive response you have never seen before, and it looks like magic in the video. Watching his dad’s face in that moment was priceless, because he was suddenly leaning in too, like, what has happened here, feeling a different level of trust around what is happening in the sensory realm that supports adaptive outcomes. It is really beautiful work, but it takes that knowledge of the sensory elements infused into the adaptive response of what is possible when you get regulated.
Michelle: I love that, Tracy, because we can see it when it happens and understand the mechanisms. I get greedy. When Kim Barthel was co-treating with us, she made the point that we were greedy, because, and I saw the video too, after Cory had this intense, really adaptive moment with the child, he fell off the ball, still watching Cory, but rolled off and moved away, ran around the room, and within a couple of minutes came back to Cory, and they repeated it, and he stayed a lot longer. Can you help me understand the rolling off the ball, or the gaps, when we see a child respond really positively and come back for more? I am so greedy, I do not want them to disconnect. My guess is that that disconnect might, particularly with kids with a profile of autism, be some flooding, whether from an affective response or a body-based sensory motor one. What might cause that moving away from something that looks so adaptive, and that they come back from?
Tracy: Absolutely. The window of adaptation does not just crystallise and solidify in a moment and then stay forever, and that is true for all of us. One thing I have really learned from children and adults who have autism is that they have a different pace and time, just like you and I do, that says, I am here fully present right now, and then I need to regroup, and especially when a new skill is coming together, the regroup and consolidation, moving away in order to move back toward, is actually the critical part of adaptation. We always move in and out of synchrony, in and out of engagement. Even listening to this podcast, our listeners will fade in and fade out, and that is the rhythm of life, the rhythm of humanity. Autistic people teach us the rhythm of humanity, and it is such a gift. So allowing a child to be with, and then move away, and come back, you see that window of engagement and tolerance grow in its plasticity, and that is what we are going for, not a set point, not, this is it, we have achieved it, we are done, but the fluidity and flexibility that is human interaction. For a child like this to have that shared experience with Cory, that was pretty full on, a big deal, rich and deep, and that is hard to take in, so let him do it and then move away. And then how cool, he comes right back and wants to repeat, and the repeat often produces even more. We know repetition is critically important, repeating those adaptation moments and then growing them, but it is not static, we cannot stay in an intense interaction, we cannot even do that with each other. We can play the eye-contact game, but we are going to have to look away, we cannot be greedy and say keep going, keep going, because our nervous system has to look away, blink, soften, regroup, and then return. So serve, return, come back, revisit, that rhythm is also coming from the rhythm of the proprioception and the movement, and that is communication, that is relatedness, and that is what is going to grow. So I imagine, Cory, once you found that formula, the next sessions must have been really juicy.
Cory: It was so fun from that point forward. The sessions before were me working hard to figure it out, and then we had this moment where I thought, okay, I have got something that really works. I did not get regimented about forcing him to redo it the same way, I found different ways to reach the similar thing, always with rhythm and intensity and usually inversion. Then he needed it less and was able to stay, which let the reciprocity be sustained for longer. It was so exciting, because he loves Annoying Orange, the YouTube clips where the orange talks, and he would be the orange, and he would let me be the hamburger, and I would say, oi, orange, what are you doing, come over here, and he would tune into that, come over, and imitate, as orange, what I was doing as hamburger. We had never had that before. It was still around a script, but it was not scripted, it was familiar but adaptive and interactive, and it was super exciting to be part of that with him. His dad was super involved in sessions too, so we were all loving it, his dad saying, he is doing so many different things. It was really exciting to be on that journey with them.
Tracy: And that pivotal skill of imitation, from regulation into engagement and reciprocity, those first three levels in the DIR model, the social-emotional developmental frame you are trained in and were using. It would be really fun to jump into that in a future episode, to talk about social-emotional development and how pivotal imitation is as a skill that allows for growth and change. Once kids authentically understand imitation, not through rote training but understand what it buys them, watch out, because all kinds of things happen from that base of engaged imitation with moments of reciprocity. It starts to make the world really different for kids like this. So how amazing that you were able to use sensation and sensory integration to find that, with him, together with him. Really powerful.
Michelle: I cannot wait to discuss the next podcast with you, Tracy. Wrapping this one up, for me, I love being reminded that I can just sit back and hold space, that when the child moves away, that is part of communication, and I can wait and be available for them to approach me. I can help parents and everybody around be available and open and ready for the return, and not contract and worry, the moment is over, how am I going to catch that again, and get antsy. I am just going to be, and help communicate that being available is what is really important, even though the moment is finished and we all want to high-five and happy-dance, you are not going to do that right there.
Cory: Mine is to be willing to ask parents to video, and to take that leap and give yourself the space and time to think deeply about the children you work with. You will quickly get over the sound of your own voice and be able to watch without feeling embarrassed, so it will really help if you take that leap, it will push you in the right direction.
Tracy: For me, this episode highlights the complexity, yet again, of sensory modulation. We spent a few episodes on it, and now this case illustrates that those mixed states of intensity and heightened responding, combined with the need for inhibition, plus the cues of what the child needs, all require discerning clinical reasoning. We cannot really do this work without it. We can approach over- and under-responding in formulaic ways, but for kids like this it takes much more. It is a privilege to hear your clinical reasoning and see how effective it is, and while it feels complex, it is doable. We can all replicate this with fidelity, and we know that from the Spirit framework, the STEPPSI tool, Ayres sensory integration and DIR Floortime, these are all replicable tools that let us articulate and identify exactly what we are doing. So we need these deep tools, and we all need to be brave enough to do this work. Thanks for your generosity in sharing your beautiful work.
Cory: Thanks ladies. See you all next time. 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!