Emerging executive functions

Lightly edited for readability. Speaker labels and chapter markers match the published episode.

[00:00] INTRODUCTION AND CASE PRESENTATION

Cory: Hello everyone, episode 10, here we are. Last week we went a bit more into the social piece, and I had a question about how much do I push children and how much do I allow, and we talked about balance, and who leads the interaction and who follows. At the end we started to work towards how executive functions play into our social capacities. So we have not finished with the social box yet, but we are starting to move you all around this amazing Spirit model. Talking about executive functions brought up a case I have been working with, and I went and got permission to talk about, which is fantastic. One special thing is that Michelle and I have both worked with this child, I am working with him currently and Michelle worked with him a number of years ago, so he really demonstrated for me this linking of the networks between the social-emotional capacities and the unfolding of executive functions.

[01:15] MEETING OUR LITTLE FRIEND

Cory: I know executive functions are a bit of a gap in my knowledge, because so often I feel like I am working on regulation, modulation and lower-level social-emotional capacities, so I almost never get this really clear example of executive functions shining in your face. So this is a great opportunity to refine some of that. My little friend is a 10-year-old boy with ASD and ADHD, just to give you context, because plenty of people will have children with similar diagnoses on their caseload, and of course they are all different, but it helps to lay it onto something familiar. He has been coming to see me for coming towards six months now, with some interruptions, and he has been a joy. He is really socially motivated, he wants to connect and interact, but he is also delightfully distractible, delightful for me because I can attune to him one-on-one and bring him back and contain him a little, though learning how to do that for him has been a process. Out and about he would look more impulsive and have a harder time coming back. He tends to want to interact socially, and my guess is that in those moments he comes to something familiar, asking questions about specific things, and he will ask the same questions to each person he meets. It is a little repetitive. Sometimes he does want to know the answer, and I can feel that difference in sessions, if I answer he is actually tuned in and listening, and other times it is just, I am going back to my familiar thing. He does that out and about, but in my sessions it has dropped off a lot, and it is far more attuned, appropriate question-asking to the context, whereas before the questions were often completely irrelevant to the moment. Michelle, do you want to add anything from before, about where you were at when you were seeing him? Posturally he is not very stable, but I have not been doing set procedural activities for postural development, it has not been the priority of sessions.

Michelle: That is a great description of him. When I worked with him some years ago, he would come into the building, which was an old Federation home with wooden floorboards, fling the door open, hi Michelle, and stomp his feet a number of times on the floor, really interested in the echoing of the hall. I would give him big affect, oh, you are so noisy, but you are so happy to be here, let’s go in. We would go into the room and it was looking and wondering at all the opportunities, and within maybe a two-minute window he might have asked seven questions and had four different play ideas, and wherever his eyes went, his body moved towards. The thing that stuck out was how socially motivated he was, he loved big affect and cheekiness, particularly with some drama, but in spaces that were less contained for him, even out of the hallway into the clinic, he got lost in the room, in the ideas, and sometimes he would not finish a sentence because his eyes caught a new thing and he had a new idea.

Cory: Totally, because even now, even though he has made such beautiful progress, he comes in each week looking like that, though less intense than in the past. It still feels a bit like chaos, oh, I need to do this, and we are going to play this, no, put the music on, no, get this, mum say goodbye to me, no push me, give me a boost on the swing, no I do not want to take my shoes off. We have the routine of coming in, taking shoes and socks off, then getting on the mats, and he has done that for years, but it continually gets missed, so I have to go, wait, hold on, we are missing something, and reorient him. Just in that transition it still looks a little like that. Partly it is excitement, because he absolutely loves his sessions. It is very satisfying, because he comes in looking like that and leaves looking very different, a clear change from start to finish, which is why I have had so much fun working with him.

Michelle: He has this strong social motivation to be with you. Eventually he will turn around and really notice me and pull me in, which is a different flavour to other kiddos who come in but without such true, embodied motivation to be with me and to connect. Sometimes it is, can you push me, but mostly it is a true be-with experience rather than a transactional, pop this up for me, do this for me.

Cory: Totally, you get the sense he really likes to be in relationship with other people. So that gives everyone a picture of who we are talking about and the journey we can talk about today.

[10:19] FAMILY BACKGROUND AND REFERRAL

Cory: It might be helpful to give the current context of what I have been doing in sessions, but Tracy, you let us know, because you are our external checker here, we do not know what people do not know.

Tracy: It would be helpful, because all of us in the paediatric therapy world have had these beautiful kiddos who are so captivating and fun to be with, but also living with this level of chaos moment to moment, and how challenging that can be. For one family, the goals and the reason they seek intervention could be because living with somebody who does not really have a stop signal inside them is exhausting, even as they cherish the on signal. So for one family it could be, could you help us understand how to help this child find a pace and a stop and start that matches our family or the school demands. For another it could be more about how unsettling it is to be with somebody whose nervous system is on go all the time. For another it could be longer-term, how do I help this child get organised enough to have friendships and independence and accomplish the things of life. And for others it can be a bigger worry, because even though this guy is super socially motivated, he is not necessarily managing working with others, with distractions, with multiple demands, the things of adult life, and some parents start to think, oh my goodness, he is 10 already and still not catching traction on some of these things. So I am wondering about the referral source, the paediatrician, the family’s perspective, and the reasons for coming to OT in the first place.

Cory: Interestingly, because I am not his first OT at Seed, it was not a specific, something is going on, we need to come back to OT. He has been linked in the entire time, with a couple of us, Michelle and me and Sarah, but he came to me without a specific referral. We have a model where kids take a break and then come back, and the way our timetabling worked, he ended up on my caseload, so there was no specific new element that drove it. Michelle has more of a sense of the initial reasons he came into therapy, but it has changed so much over the years as to where the priorities are. I am sure many of the things you said resonate with the family at different points. My sense is they totally delight in the oddness, his moments of being on and the way he interacts, they get a real sense of joy out of those moments, but in the same vein those times of not being able to stop are exhausting. So there is also a wanting to move towards helping him connect in a more robust way that lets him stay with, be with, and work together.

Michelle: Early on we joined with the family and there was not a diagnosis, so they have been on a long journey. This little delight is the third child, with lots of support from aunties, uncles and grandparents, a really socially active and involved family in the community, so his strengths really match the immediate and extended family. They delight in and share his interest in people, in being involved, in following all the sports, with lots of cousins. Over time, as he moved into school, some of the focus turned to activities of daily living, how to get him dressed in a rhythm and eating without pulling the family into chaos just to get out the door, because both parents work and the older kids needed to get to school on time. There were practical issues, how to select a school, how to support him in a mainstream school. As a mum myself, we always wonder about the future and how it will look, and this family, with all their children, trust that everything will be okay, that this boy will be supported and find his place, with lots of people who love him around him. Sorry, I am getting emotional.

Cory: It is the joy and delight we have in working with these families. There is some dance in and out, he has lots of strengths that match the family, and over time, in different contexts, it is, oh goodness, we have to work on sitting still in circle time, but the flavour is, he will be okay, and so will they. I love that you get emotional, it is because you care so much, it is a beautiful match.

Michelle: It is not lost on me how tricky the day-to-day is, but it is a really good match.

Tracy: Michelle, your empathy and connection are so valuable, and every one of us has to walk that line of empathy and connection and relating so deeply to the real human story that is true for every kid and family we work with. You both talk about that dance, the flow and emotion of it, and that is so real. Caring is the reason we do this work and it fuels us, we are going to be touched and feel it, and we should embrace that. One of the struggles we have as clinicians is to be in the present moment while, as OTs, being so goal-focused that we are also thinking about the future, so that combination inevitably leads to deep, ranging emotional experiences, and that is all good. It is also a reflection of the struggle, because sometimes families have a lot of resources and community support, and lots is possible, and yet this little guy is struggling, with layers of diagnoses added over the years. When kids have multiple layers of diagnoses, it is a reflection of multiple levels of complexity, and from a clinical reasoning standpoint that complexity can make us ask, what should I focus on here? Especially around this broader, big regulation issue. On the Spirit form, the concept of regulation shows up in a formal way across three different big functions, a reflection of how much of our whole nervous system is involved in how somebody comes to be organised and reach full capacity. For somebody living in a lot of chaos, we feel that chaos and can have a hard time naming the cornerstones, so the Spirit tool is really good at helping our clinical reasoning connect to the key capacities we need to build, and it clarifies the focus of treatment. So it will be fun to think about this guy from that perspective.

Cory: Beautiful, I am really excited to explore this further. I hope we have given everyone a good sense of what our little friend looks like, how he is in the world, and where the family is coming from.

[22:31] CURRENT THERAPY APPROACH

Cory: Now it is probably helpful to give the current context of what I have been doing in sessions, then we can unpack it and reflect on these functions. I came to my little friend with fresh eyes, I tried not to have too much of a picture of how I expected him to be, I just wanted to meet him where he was at, and the first session was 100 per cent Michelle’s description. Sometimes with older kids you feel a bit funny doing things like singing songs, because you think they are probably too old for that, but he just wanted me to go there. Even in that first session he wanted to sing nursery rhymes, so I said, all right, let’s sing nursery rhymes, and it was in that moment that I had the most regulated connection of the whole session. There was a lot of impulsive shifting of ideas and moving between things, so once I got that little moment I thought, oh, I see your jam, I need to go there and be willing to go there, because that just works for your nervous system.

[23:59] EXECUTIVE FUNCTIONS UNPACKED

Tracy: Let’s deconstruct a little of what that means, because it is really important. For a little nervous system struggling in chaos, predictability, rhythm and familiarity are cornerstones, and doing it with the human voice. Our sense of connection that comes from predictable rhythm is a very early skill, and it is actually one of the threads these higher-level capacities develop out of. So when you connect in and help him find that place of sharing a song you both know, getting into the rhythm of it, you can then enhance that shared experience. Talk a little more about how the social sharing, the sensory qualities of rhythm, and the predictability might have been part of the formula for him.

Cory: Let me try to remember how it happened. He had decided, let’s read a book, and gone out to the little book crate in the waiting room. I thought, let’s see where this goes, because I am willing to go there with kids to see what happens. He picked a nursery rhyme book, so I said, great, let’s do that. We took it back into the room and I put up the rainbow, the Lycra Rainbow, and he got into that space and we read the book together in that contained space, and he looked really settled, which was nice. We did not read the whole book, and not every rhyme caught him. Then, I cannot remember exactly why, I put him on the log, our bolster swing, and he wanted to sing those same songs on the swing. It was a really cool moment, because I was giving him movement and rhythm while sitting in front of him where he could access me easily visually, and I could add novelty and rhythm through how I gave input to the swing through his body, and we could sing together.

Michelle: And the log swing was going backwards and forwards, so he is approaching you and withdrawing in a rhythmical way, coming towards, coming away. And did you both sing together, did he know the words?

Cory: We did, he knew the words. I would offer him the choice of which song, open the book to that page, this one, yes that one. At that point he was not pumping the swing robustly by himself, so I could give him rhythm around the timing of the swinging to that specific song, or just bump on the front of the swing with some rhythm, and then we would sing together. His voice modulation for loudness is very loud, but it looked a lot more organised than the rest of the session, a clear mark of, this is where I am getting it. I needed to have no reservations about doing this with him, even though in the back of my mind I know everyone in the waiting room is probably wondering what is going on in there, or how is this therapy. But it was so clearly his best moment that I thought, I just have to go here, because this is where he looks the most organised, so I need to follow this with him. I did not start by deciding I was going to sing songs.

Tracy: I appreciate that in allowing him to explore what might be interesting, sometimes kids have this internal wisdom of, I need something familiar and simple. There was something familiar about that book that helped him share the moment with you, but then your ability to enhance the vestibular repetition and rhythmicity, and help him find a rhythm that settled him, while maintaining the shared social moments of the song, crafted a really important moment where the sensory-motor world and the social world come together in a shared task. It is not an explicit goal like, we are going to sing three songs, we are in a moment together and sharing it, enhanced by your ability to offer equipment that allows for that, in a way that builds toward a shared moment. Knowing you are working on shared, reciprocal moments is important, but what it does for him is organise him so you can start to have a more prolonged sharing unfold, which has been tricky because he tends to be so flitty in his attention that he does not hang on, hold on or stay put. In the Ayres literature, Dr Ayres identified that hold on and stay put is one of the very first adaptive functions that allows higher-level capacity to unfold. So your discovery is a seaming-up of what he needed developmentally. It could look to anybody else like, yeah, whatever, but the essential qualities coming together in that moment are what his nervous system is looking for, and that is what lets him think, I want to repeat that with you, that was pretty cool. Hooking into that internal motivation to repeat and share and enrich it with you is really where the hook into neuroplasticity is, and that is what you are doing.

Michelle: And is that the hook into where executive functioning can start to emerge, that when he has that motivational bias, I want more singing, I want more of that, the shifting away does not occur as much, and therefore attention builds, his capacity to stay with. Is that what we would refer to as attention?

Tracy: That is precisely what it is. In the Spirit tool, we get to executive functions through an affective function that is quite high-level, what we call the high route of the affective (A) function within Sensory, Affective and Motor. Motivational bias is where the system pulls you, the function we attach our bootstraps to and pull ourselves forward from. So if we have kids with this motivational system really switched on, it is a lot easier to see their attentional capacities unfold. The executive functioning system is quite complicated, because it has cognitive overtones but is also deeply emotional, and it draws from the sensory, affective and motor systems as the threads that weave it together. When we have kids like this little guy who do not have all the bits and parts that make up the attentional system, treatment can feel chaotic for a moment until you find where it resonates for the child. For him, what resonated was sharing a moment with you, and you could reinforce it by giving connection, rhythmicity and movement in a repeated pattern that let him stay with you. That stay-with-you function is made up of a bunch of different executive functions. One thing that is really tricky for this guy is stopping, what we call inhibitory control. That ability to hook into stopping and hold the stop signal is pervasively hard for him, cognitively, socially, sensorily and motorically. Inhibitory control is essential, consolidating around that stop signal, my nervous system is going to help me stop. But when a lot of these kiddos stop something, they can lose track of what they were interested in, which is a working memory problem, and you can see those two things competing in his day-to-day chaos, he is interested in one thing but cannot stop the other, or is so interested in something that he loses track of what he was doing. These core executive functions of working memory and inhibitory control often go awry when we treat kids, and the tricky part is that just saying words, we are working on this, or stop doing this to do that, does not allow the system to sync up. Although it is a high-level system, it really depends on shared motor synchrony and shared social experience to catch its key elements, and once those capacities are available we can build on them from a more language-based or cognitive perspective. If there is nothing to hang on to, the words end up empty. So you are doing such a nice job of helping him get the key bits to have something to work from, and what has been elusive to him until now will start to catch traction.

Cory: So let me put this together. The sensory-motor, relationship, rhythmicity and timing piece I was doing in that moment, and have continued over sessions, gave him access to inhibitory control through the motivational system. The high route of A, in my mind, is the more cognitive parts involved in, what am I interested in, what am I going to stay with because I am interested. But I came to that through his existing drive for social connection, paired with how his nervous system resonates with rhythm, timing and predictability, plus being aware his postural control is not great, so sitting where he could find me easily, and giving him rhythm through the sensory-motor piece, all let him do the stop and stay-with for longer. The first time it was not long, but that is where I noticed, oh, I have hooked you in. Is that the foundation, the building blocks for more executive function, the inhibitory control to stay with the things I am interested in for longer?

Tracy: Yes, very often that is exactly true, and I think it is for your little guy, because even when he was interested in something he would flit away from it. The motivational system and the effortful control system, which is a partner in the executive functioning network, work together, and we will put a little visual in the show notes, being created by a consortium of researchers, because we are talking about a lot of concepts. When kids feel motivated by something, the desire to stay with it, that persistence, control and grit, I want to do that again, starts to be the driver that helps you say, I want to repeat that and I am not going to do that other thing. Very often when kids go through the emergence of this, they get really interested in building Lego, or colouring, or reading, and forget to go to the bathroom because they are so engaged that they lose track of their bodies and of tuning into their interoception or other cues, they are so motivated they are overly motivated, which is something we end up working through over time. So this hooking into, I am interested in that, so I am not going to pay attention to the thing that catches me, is a really important set of skills. We see it in little kids, I am going to stay with this, I want to try it again, and you hear that language, let me do it again, watch me again, I want to go again. Then the attentional system is like, I can do that longer, I can stretch longer and keep my focus. It can get sticky too, where kids are so drilled in that they are not going to be flexible or shift their attention, so there are lots of little bits to work through, each a little sticky in its own right. What the Spirit tool and clinical reasoning help you do is ask, what are the skills available right now, and what is hooking this child into the next higher capacity. With this guy, as you help him, I want to do that again, I want to repeat that with you, and you give yourself permission to just say, let’s do that again, that was super cool, his ability grows, paying attention for three minutes is a lot more fun than for 30 seconds, and that success warrants a lot of progress.

[44:35] PROGRESS AND REFLECTION

Michelle: I love looking at what that motivational bias is for him, but I also want to comment on the things that are tricky for him. That staying-put physically, the action regulation, Cory helped contain by popping him over the log swing, hanging on in front of him, legs abducted, a little flexion in there, providing some inhibitory input that helped him stay put. And the nursery rhymes, which he presented to you, contained his words, they let him speak but kept him on task and on topic, so he had some inhibition verbally, where he can often be impulsive verbally as well as physically. So you were doing both, working towards what he is motivated by while noticing, I know you did not pick that log by chance, Cory, that you were facilitating the inhibitory functions, restricting him somewhat so he could stay put.

Cory: Totally, and the extra element in that position is that I made sure the log was at a height where he could still touch the ground, because I knew it would not be helpful without him being able to use his feet to stabilise his body. But you are right, that swing gave him containment in the motor action system, because getting on and off that swing is not easy for him, so once he is on it, it is, now I am here and anchored. And I know that swing, if you are not sitting on it like that, can give really nice linear vestibular input that also helps anchor him. And I sit below his eye level, right in front of him, because I know that helps relationship-anchor him.

Michelle: And stop those eyes flicking off.

Cory: They do that, and at our most recent session there is still some moving away and in and out of that, but it is so much longer now.

Michelle: You have set it all up so it is easier for him to come back to you, rather than him literally out in the waiting room or on the loft. So it is both, that bias and helping add elements that facilitate the inhibition to stay there. Even when his eyes go off and look out the window, which they do multiple times, there is a pause where he might want to do that, but because you have positioned him, his body does not, so he is not bumping into action dysregulation.

Cory: Yes, and he is anchored enough in everything else to then show the inhibitory control of seeing something else, then remembering, oh, I was in this thing, this was fun, I am going to come back to this. Just now I have had the revelation, he is doing that bicep curl of inhibitory control so many times, I am looking away, orienting to this little toy, and now I am coming back to you, looking away, and coming back to you. That is me helping support his attention function, oh, I can do this longer, I can stop and come back, which is a really cool stop for him. Thanks for helping me see that, guys.

Tracy: That is exactly it. Once you get to those core bits, you identify it, it is almost like a neural exercise, how am I strengthening the bicep, how am I strengthening the attentional control, stop, come back, stop, come back, where he is driving it, using his own capacity because you set the scene for him to anchor into it. Those are the ahas we all need to guide our treatment.

Michelle: Otherwise you can dismiss it and think, oh gosh, these nursery rhymes again, what am I doing, or feel the pressure of, he is 10, I should not be doing nursery rhymes anymore.

Cory: Or not clearly seeing where the actual work is happening, because unless you stop and reflect and think about the fact that that is the thing building the capacity, you do not see the value in staying there. And it starts to expand and unfold in its complexity naturally, I should not have to push or enforce that unfolding, it will come about as we go, and it is just starting to now.

Michelle: Three years ago, the way I was doing that was we had to be in the rainbow Lycra together, sitting with one of the layers as the roof, and I would be just in the opening. We would use kazoos and he had an item of choice in there, but once we came out of that space he was not able to stay with. So there has been a massive leap, that you are in this big open room with a massive enticing window to look out, and he is staying with, where before he could only do that if I really visually occluded the area, had big affect, and was really close, in that mother space, perhaps half a metre away, big and juicy. So over however many years, he is in an open, big, inviting space, and you have moved much further away from him.

Cory: Which is really cool, because you can see how far he has come and go, woohoo, look at that. These kids show us these things, I do not think I have ever had progress so clearly, and it highlights the value in following the thing that resonates with their nervous system. If I had had too many reservations about, oh, you cannot sing Wheels on the Bus.

Michelle: I saw Cory sing Wheels on the Bus with gusto, like she is at a concert. Bob the Builder, she air-punched Bob the Builder.

Cory: I was totally in it, because he was so in it, and it is so exciting to me. My nervous system absolutely loves those moments with these kids, when you find those things and you can see the joy written over their face, this has hooked you right in and I am here with you. It is a fun journey to be part of as the therapist, and that is where my juice comes from, look at you, and I get to be part of this.

Michelle: You are in it too, let’s be honest.

Cory: Oh, totally, I am fully vibing off his vibe, and I do not care what it takes, if that is Bob the Builder, I am totally in there. That is part of my own profile, it does not take much for my nervous system to feel, ooh, this is cool, I can delight in the things that are childish, which is probably super helpful.

Tracy: It is super cool, because this work is so spectacular, in the moment with the child you get to have these resonant, joyful, gorgeous moments, and then we get to do clinical reasoning where we understand why we are doing it, and do it again on a different level. That is very fun.

[54:14] CLOSING THOUGHTS

Cory: This has been such a helpful discussion. We should totally talk more about executive functions, because it is complex, and there is so much more for me to refine around understanding those higher-level capacities and how they come together. It was a really good introduction for me, around the high route of the affective function, effortful control, and how that is supported by motivational bias. I started to get a sense of that today, and how, as a therapist, where there are gaps or challenges in the sensory-motor coming together or the postural systems, if you can find that little bit of traction in those things with what they are interested in, you start to see more effortful control and inhibitory control around staying with you and with what is needed. We could definitely move to those kids who get stuck in the, I want to stay with this. I would love to talk more about all of that. Thanks, guys, what an awesome episode, can’t wait for the next one.

Tracy: Great to be with you guys again.

Cory: Thanks, Trace. 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!