Michelle planned a session full of ball play. Her young client showed up with a drippy nose and a mask, and what unfolded, learning to blow his nose, turned into some of the best therapy she had done with him. This is an episode about the surprises: how a child’s own motivation can unlock attention, problem-solving and regulation that no planned activity could, and how to reason your way through the mess when treatment refuses to go in a straight line.
We pick up the little guy from Episode 3, the praxis episode: a clever, social, ideational nearly-six-year-old whose sensory discrimination, postural stability and motor execution make him slide laterally, changing the goalposts, whenever something gets hard. Michelle came in armed with a kit for ball play and some new language for error-making, and he ignored all of it. Then, deep in COVID and wearing a mask, he arrived with a drippy nose and an actual, urgent, self-generated goal: I need to blow my nose. Michelle followed it, and across that session and the weeks after, shoelaces, balloon-blowing and tying, he stuck with self-care tasks far longer than she would have predicted, monitoring, problem-solving and staying regulated, because the goal was his.
Tracy unpacks why: the high route of A, his own motivation, pulled him into a different kind of adaptation, and Michelle was there to scaffold the weak pieces, sensory discrimination and interoception, in a playful, embodied way. She walks Dan Siegel’s four E’s of cognition, embodied, enacted, extended, embedded, as a map of what Michelle did, and uses canalization and a Texan cow-path analogy to explain how a new, more adaptive pathway gets carved when motivation and connection do the work. Cory adds her own story of teaching a teenager with an intellectual disability to manage zips across an intensive week, reducing the demands and using her affect as the motivator, when the goal was not the child’s own. It lands on the I can space: motivation as a high form of regulation, and the moment a child looks up and says, I did it.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Cory: Today we are going to continue on, although you can totally listen to this episode without going back to episode three. We are going to take the little cherub we talked about in episode three further along the journey. We left that part of the episode open, clinically reasoned through it, and Michelle was going to take it further. People have been asking what is going on with these little ones we have been talking about, so Michelle is going to give us a refresher and take us through what happened next in sessions with him.
Michelle: Our treatment model is that they come weekly for a block of sessions, then have a break, which lets us see another family, and then come back. The last session I explained in episode three, The Power of Praxis, was this little guy, nearly six at the time. He came with sensory-motor challenges, specifically sensory discrimination that was impacting his postural stability and his planning, particularly that motor execution component. He is a clever guy, and his strengths are his playfulness, his drive to be social, and his ideation. So he has this pattern of coming up with lots of ideas and working around it when he is not successful, changing the goalposts. In that last session, there was a ball in the room, and he started willy-nilly kicking it around, every attempt in another random way, his feet, then his knees, up the ramp. We were discussing the need to stay attuned to him, follow his lead, and be ready for his invitation to become more masterful, so we could infuse his play with more skill, refining his sensory discrimination, and the executive component of praxis where he notices an error, problem-solves, acts on it, and re-evaluates. So I went away after the episode and brainstormed, right, when he comes in next, what activities could I have crafted and ready? I came up with some phrases and language around when he makes errors, to offer him the chance to have another try, I wonder what we could do about it. So I came in with a big kit on the ready, balls and noodles available. And he pretty much repeated the last session, bounced around, ignored my new little things, and kicked the ball around. I was thinking, I need a hotline to Tracy, what next? But I got the feel, wait, wait, just hold, the opportunities will arrive. And this is the aspect I love about our job, that kids keep surprising you, and we just have to be on the ready and around a lot of theories and practices, because you never know what is going to show up.
Michelle: So the little kiddo came for session two. We are deep in COVID, so he was wearing a mask, and it was spring, so he had a little clear, dribbly nose. He was quite alarmed, saying, I do not have COVID, I have a dribbly nose, it is uncomfortable with a mask on, what am I going to do? As we are walking into the room, which had balls everywhere, I said, oh, I know lots of kiddos who have trouble blowing their nose, I can help with that, would you like to work on it? He said, yeah, sure. So we sit down, I quickly remove the balls, grab tissues, the bubble mountain, and a harmonica from our oral motor kit, just thinking, I knew exhaling out the nose was not readily available for him. We started exploring what to do next. In my mind I had to backpedal, wow, we are going into task analysis, into ADLs, into self-care. But he is highly motivated by this, which he had not been in the past, so I was thinking, how long is this going to last? I just went with what he was offering, which was not in any of the stuff I had thought about. And it absolutely involved sensory discrimination, planning, goal-directedness and being masterful in a discrete skill. So I went with it, and it was fascinating, an about-turn for me, which is a learning in itself.
Tracy: It is probably helpful to know what bubble mountain is, because not everybody does.
Cory: Yeah, our lingo that we forget people do not know. We just fill a bucket with a little water in the bottom and some dish soap, and we have what we call a chewy tube, basically a big long rubber straw, Theratubing. You blow into the water at the bottom, and bubbles start to form, up and up and up, until it looks like a mountain or a volcano. It is an oral motor game we use to extend the breath, a long exhale through the tube.
Michelle: It gives that visual cue of a long exhale, which can help with regulation, and lots of oral motor coordination. We have done it before for regulation, so I knew he had a long exhale through his mouth, and I thought that was a nice way to start, for him to get oriented to his mouth and pay attention to breath.
Michelle: So we were doing that, and I really highlighted that he was doing a long breath out his mouth and a big inhale through his nose, so breath was going in different places. Then I pulled out the harmonica, because in my mind you could do both, so he was breathing through the harmonica in and out, exhaling through his mouth, which was not much of a leap for him. So we quickly moved on to, let’s close your mouth and see if we can blow out your nose, and I had tissues around so he had to flutter them. There would be more fun games, but you are going quickly. Then it was, okay, now all through the nose, in through your mouth and out through your nose, and we did the same with bubble mountain, a long slow low-tension breath through the nose, or a short sharp honk for a hard nose blow. So we played around with how to make air come out your nose, shifting air in and out of mouth and nose, being playful about force and coordination. He was just in the moment of it. I gave the girls in the office a giggle, because traditionally I do not get to work on refining tasks at that level, nose-blowing has not featured in my sessions for a long time, so I was like, I am blowing noses. He stuck with it the whole session. His mum had ducked out, so he ran to the waiting room, can I show Mum? He did a little blow that was not going to clear the passages, so I said, let’s try that again, and he ran back, got his really big honker blow mastered, and went out and showed Mum. Over the weeks he kept coming with ADL tasks, shoelace tying, then undoing a double knot, then balloon blowing and tying. I could not believe it, the goal was driven by him, he identified it and kept showing up with it, and he showed so much more capacity to stick with it, monitor, problem-solve, stay regulated and stay on task. I was bored, thinking, I will do this nose-blowing for seven minutes and then we will get on with the session, but these tasks were the session, and I was the one being surprised, because he stuck to it and showed far superior skills in adjusting, refining and regulating. I did have a mini-tramp and a rainbow swing out, so when he got a little frustrated he would use those, shake it off, and come back to task. His capacity was far greater than I would ever have given him credit for. Success bred success. I did have to do some weaving, because I knew if I just focused on splinter tasks I would not get to the underlying issues, so I tried to infuse some tactile discrimination work without annoying him or dampening his motivation, to help him seal the balloon closed, for example.
Tracy: I am the executive director of a nonprofit in Denver, and there is this guru of nonprofits in the United States, Joan Garry, who says all the time, nonprofits are messy. I always extend that to, life is messy, therapy is messy, and providing intervention can sometimes feel messy. But based on what you said, Michelle, I want to recode it, because you started by talking about how you are constantly surprised. The first thing I want to say, maybe an Aussie thing, is good on ya, because the truth is we have to be brave, trust, and rely on all of our knowledge and our ability to show up and hold the relationship with the child and the goals, and then just see where it goes, and it is sometimes messy. Therapists who want it to be linear and sequential really struggle.
Cory: I am laughing because we all want it to be linear and sequential. Imagine our notes and our planning and our goals and our reports. You just continually wrestle with wanting it to be clear and linear and it not being.
Tracy: Even in Bruce Perry’s Neurosequential Model, where the idea is sequential, it is not sequential in the way it unfolds, or in the way we scaffold it. So regardless of the framework, when we are with kids, clinical reasoning is critically important, which is why I love that we do this podcast, it lets us reflect together on this non-linear process. Michelle, your ability to respond and hold and co-create with this boy in the moment is really beautiful, and that working towards adaptation is what occupational therapists do all the time. When you were trying to figure out the ball scenario, sometimes a child’s needle gets stuck, and when we follow their lead and their needle is stuck, we can get stuck too and feel bogged down. The authentic thing that happened for him was that his nose was drippy, a real thing, and what shifted there was pulled by that high route of A, the motivational system. When his motivation pulled him toward, I want to do this, and you helped him figure out how, that is a beautiful, authentic following of his lead you could capitalise on. He was ready in a different way to meet that adaptive challenge, and your lens of tuning in playfully to the elements that were weak for him, sensory discrimination, interoceptive awareness, and turning up the dial on how he could embody the experience of blowing in a full, rich, discrimination-informed way. When we see that higher route of A switch on, we often see this more cognitive lane activation. Dan Siegel has these four E’s of cognition that I think you danced through, so it would be fun to mention them.
Tracy: He talks about four E’s of cognition. You start with embodied, you have to have this sensory-motor experience, really laid in the sensation that allows for the skill, so here interoception was critical for him to embody. Then embodied, enacted, extended, and embedded cognition. Dan Siegel is a genius and I am drawing from his work, so go to the primary source if you are interested, and we will put that in the show notes. Applying it to the situation, Michelle, you were first helping him embody it, playing with the interoception, helping him explore it. Then you were enacting it, putting it into an adaptive act, and at first it was not quite nose-blowing, it was pre-nose-blowing, and he could enact that, have success and find mastery. When you keep that mastery drive switched on and move from embodiment into enactment, you can extend it, you have variability, you can use your mouth or your nose, in or out. And then you embedded it in the actual skill, in context, in something he could leave and take with him. So you danced through those E’s and pulled him into a full adaptive response, and that is what skilfulness is all about.
Cory: It is your intuition. You have all the OT task analysis at your fingertips, so with no prep you followed his lead but on the go knew the components to highlight for him, weaving in the discrimination and interoceptive pieces.
Michelle: The bit that allowed me to do that, that had not shown up so readily for him in sensory-motor tasks, especially an ADL-like task, is that he stuck with it. Previously he would have moved the goalposts, pulled the tubing out of the bubble mountain, flicked it, popped the bubbles, and said, bored with that, I am moving on. This blowing-out-the-nose stuff is a bit tricky, particularly when in the moment I could not come up with anything more exciting than fluffing a few tissues in my hand. But his motivational bias, that drive, had him hanging in there through a tedious task. He had wider boundaries to sit with it, and because he is social and affect-driven, I got goofy about it, which gave him a bit more scope.
Cory: It seems like that piece recruited the effortful control, doesn’t it, Tracy?
Tracy: Absolutely.
Cory: That is obviously that higher route of A, strongly motivated towards the task, pulling online and connecting to the executive function of effortful control and grit, which seems a bit weak for him in other situations. Even when he is interested in something, if he gets a sense of it being slightly too hard or he is not as successful as he hoped, he changes the goalpost. Is that what happens?
Michelle: I think two things happen. There is an error, and instead of, how will I fix that error to keep on goal, his brain jumps, sparks, to a light bulb of, how do I go around that? So he does not stay on task, it is more a lateral problem-solving, probably because his postural stability and motor execution have been lower and slower, and his discrimination, while his cognition is a real strength. So he cognitively goes round and round. That has been his neurological pattern, think a way around, rather than stay on a task.
Tracy: What is so important to pause on is that in that cycle of four E’s, the first is embodied, and in his body he tends to move laterally, in his attentional system he tends to move laterally, and in his problem-solving he tends to move laterally. Sometimes we see this deep reenactment from embodiment into the attentional system, the same kind of processing. It does not have to stick that way, but his occupational habits are to be lateral and not refine and go forward in this more effortful way. So when we harness this high level of motivation, it helps him embody it, enact it, extend it and embed it in a different way, which creates a new habit pattern of adaptation and broadens his neural network. Our clinical reasoning lets us come back to, what does he have capacity for, and where are we stretching him. We are in the high-level executive functioning framework on the Spirit tool, connected to that high route of A and a very broad attentional network. Attention is what directs our effort and energy. If we attend to something in a way that is more whole, the attention gets bigger; if we attend and then laterally shift to dodge out of it, attention is blunted, which has been his pattern. So now he is finding, if I stay on my motivational task and you scaffold my sensory discrimination, something new happens, in the shared occupation of let’s explore this and play with it. And your mastery, Michelle, of affectively, playfully making it interesting enough for him to stick with it, and his motivation to do so, broadened the whole experience.
Cory: I was wondering, because he kept coming back to do this with many different tasks. You talked about him moving laterally instead of continuing forward in this effortful way. In Michelle doing that with him on this task, did she start to build the neural network capacity for that to be available to him? Is that what you mean about the attention system getting bigger, the network getting stronger to sustain it?
Tracy: That is exactly right. These are pathways we carve out. There is lots of terminology in the neuroscience literature; one that paints a picture for me is canalization, you are digging a deep canal. Marty Smith, an OT here in the United States I collaborate with, lives in Texas, a state with a lot of cows, and she uses a cow analogy for how they walk the same path through the grass.
Cory: Yeah, walking the same path, the animal track, you can really see it, especially out here. It gets wider and more entrenched.
Tracy: So if it is wider and more entrenched, and he keeps walking the lateral-shift path, you came along as the new leader of the cow pack and created a new way of saying, wait, let’s stick with this in a different, wider way. In the nervous system, the strong connections are in the fast processing, so in the slower processing we say, no, I am going to inch you over here and help you see you can connect in a different way. It is speculative to say we are influencing this level of processing, but when we see a change in adaptation, that change is only happening because something shifted.
Michelle: And it kept showing up week after week. He kept surprising me, I want to blow up a balloon, and we repeated the similar structure, observed it, I wonder what did not work, broke it down. So I fell into Dan Siegel’s four E’s, and probably more of a collaborative problem-solving model too, Ross Greene’s, kids do well when they can. I was trying to keep him interested, because I know he has gone off in the past, but he just kept showing up with it. It blew me away, I was telling the girls in the clinic, I am tying up balloons for a whole session. What is fascinating in the context you are talking about is that the task was repeatable, he practised at home, but he also wanted me to repeat the process, which makes me think that whatever neural adaptation was happening, he wanted more of it across different tasks.
Tracy: Absolutely. And Ross Greene, we will just say kids do the best they can when they can. So when he is with the balls, he is doing the best he can, because his lateral thinking could not get him on a path forward to something more skilful, he was stuck, related to our previous analysis in episode three around his ideational praxis. We are still talking about those functions, but now on that spiraling continuum that advances forward. He has found a new landing pad to springboard from, using his own power of motivation to find a higher level of adaptation. When we work with kids to find those springboards, it feels wonderful to us and to them, it feels like, I am the master of the universe, I have mastery drive here. It is the most beautiful affective shared moment, and they need it, because the richest, most productive development happens in the interpersonal space, in the shared moment.
Cory: This makes me think of the cows walking down the paddock, ingraining the pathways. When you lead them down a new, more adaptive pathway, the nervous system wants to start doing that instead of the lateral shifting away.
Michelle: But I am even thinking that he was leading me, he is the leader of the cow pack. I was still with the balls, gross motor, lots of spatial challenges, and his bilaterality in his lower limbs is not as good as his upper limbs. So he was like, whoa, Michelle, we are going down this gross-motor, impulsive, high-energy path and I am not at my best there, how about I take you down to a more sedentary, fine-motor, cognitive pathway where I will do better. And he did. We still need to go to the gross-motor ball activities.
Cory: But maybe he has more capacity to do that now.
Michelle: Maybe. But he was leading me, so I am not going to claim I was the cow leader.
Cory: No, but you made the pathway more meaningful by having that interpersonal experience around it. And so did his mum, just by nodding in the moment, which meant he could race out and share successes with her, then come back and try again. He kicked the balls to the curb, not you, and grabbed the tissues, balloons and shoelaces.
Cory: The other thing that came to mind is this whole, sometimes it feels like we need to teach a skill and the child is not as invested, like we really need them to learn to use the toilet, but they are not into it yet. I thought of an example, a number of years ago now, a teenager I was working with who had a quite moderate intellectual disability, and there were concerns because she could not manage her zips and clothes independently, a real privacy issue coming into puberty, so it was a big goal. The discrimination required, visually seeing the zip, knowing it matches, fitting it in, knowing it is pushed all the way down, was really hard for her, similar to your little guy with the balls. And she was not motivationally pulled towards being successful at her fasteners, it was not something she would come to me and ask to work on. So I had to change the way I approached it, because we have all had the experience of trying to force a kid to learn a skill when they are not invested, and it feels like pulling teeth. For her, I had a week of sessions blocked out, an intensive model, so I knew I had time for the repetition that you can lose week to week with skill-based things. I took it really slowly over five days and started really simply, what is the very least she could do and have success, and I jumped on that and was so excited she had done it, because she was super socially motivated, if your affect was impressed and reinforcing, she could catch onto that, which sustained the effortful control a little longer. It started with such simple nothing, and by the end of the week she was doing up her zippers. But I also had to say, we will just do two more, I can see it is really hard, you are doing really good, because there was this level of, I really need to help you get this, and I can see how hard it is given your current skill, your sensory discriminative system, your postural system. There was no way I would expect her to stand and do her fasteners, she had to sit, we had to take out some difficulty because it was not going to fly.
Tracy: Tell us a bit more about that clinical reasoning, how you sorted what to simplify, what qualities to amplify, how to scaffold and structure her.
Cory: It is interesting, because it was years ago, so I can reflect and go, there are lots of things I would do better now. I was only a couple of years out, but even at the time I remember thinking, this has to be, I have to make the first time as successful as possible. So the task could not be putting a zip in and getting it to the top. I had to take other elements out, maybe the first thing is just holding one side of your jacket and moving the zip up and down without the other side even attached. And I had all these things she liked to do right after it, so it was, we are going to do three of these, and I gave a really clear end point of how long we would do the hard activity before moving into something she loved. I have worked with you a while and know you love that, so she could grasp onto that set-up in advance, that predictability, going through some of your STEPPSI.
Tracy: STEPPSI can be helpful, and if you had known it then it would have helped you think it through. But predictability is not only in STEPPSI, it is a logical piece that supports structure, and external structure sometimes supports the ability to carry something out, it alleviates needing to hold onto it internally. So there were so many intuitive pieces you were coming to. Developing strong treatment plans is a journey over a career, and it is cool to share a story from earlier, before you studied a lot of different approaches, and how different it would be today.
Cory: Yeah, I knew I wanted to work on this skill, my capacity to break it down, task-analysis-wise, matching her current skill level, how much she could discriminate, see where the zip was going, feel whether it clicked in, hold it, and coordinate two hands to pull the zip up. Even my knowledge around that was not as good as it is now.
Michelle: And even posturally, you said she had to work sitting down, so you eliminated that postural demand for her.
Cory: Totally. I do not even know if I purposely thought about that beforehand, but I intuitively could see it was not going to happen. There is no way she could have done that standing up and coordinated all her body parts. All I was really good at, at that time, was playfully supporting her to stay with it. I knew I had to reduce the task demand, that the just-right challenge had to be simpler, and that I had to reinforce when she did anything close to what I wanted. If I had been better at the other pieces, I would have set her up more with her tactile discrimination beforehand, or known to get really big zips first before the jacket she was using. I just started with the jacket she had and went from there.
Michelle: Sometimes you just have to get resourceful and creative and go with it, versus when you have time and can make your elaborate craft activity. Instead of relying on your affect to drive her, you might put it at the end of an activity she loves, like a swim, so you are facilitating her to undress to go in the pool, which is naturally more motivating. In the ideal world, when it all lines up linearly, you can have a perfect plan.
Cory: The cool thing about that situation was that I did have somewhat of a plan, because she came in for this specific five days. My ability to reason for it now would be different to back then, but I got to the zips in the end, and not just me, good on her, she did it, and she was so happy about it, with that mastery drive. She was not always 100 per cent successful, but she could feel something becoming easier, becoming a thing she could do. I wanted to bring that up because there are situations where it is, we really have to do this, and I do not know how to get the child’s motivational system on board.
Michelle: It is somebody else’s goal, and we see merit in it, or sometimes you advocate, you know what, they are not quite there yet, so you advocate for the person.
Cory: Or environmentally they need to manage their bowel for school, and it is, how do we go about this. I always draw from my neurodevelopmental frameworks, well, they are at this place, so what is the next stretching to, because the people around them want the next stretch to be full toileting, when actually the next stretch was just this.
Tracy: It reminds me that within our discipline we think about occupational outcomes through task analysis, but really also through that, I can do it. It is taking the im off impossible, getting rid of the im and making it possible. That might sound corny, but when you are in the space with the child or adult you are helping, if you can help them find, I actually can do this, I can blow my nose, find joy and stay regulated, that is powerful. There is an interesting thought here about how the motivational biasing system is a high level of regulation. We often talk about dysregulation and all kinds of images come to mind, but even in a dysregulated state, if you are in an I-can-do-it state, I can accomplish this, I want to do that, it pulls you forward. So that state she got into, maybe I can do this, as soon as you switched her into, maybe I have agency and power and capacity here, that keeps you moving regardless of the difficulties. The I-can space is one we always want to find with our kiddos.
Michelle: In a really genuine way. Not that they cannot be astronauts or land on the moon, but genuinely, you can achieve whatever you are setting out to do, believe in yourself.
Cory: I love that, because that is why I like doing the work, that is why I keep coming back. People used to say, isn’t it sad working with people who have difficulty doing X, Y and Z, and I would say, actually it is so satisfying, because that first time they do something and look at you and go, I did it, you go, yeah, you did. It is so exciting for that moment to come about.
Cory: A great way to finish up today. We will see everybody next time we record, and maybe I will have a baby.
Michelle: Let’s do it. Bye everyone.
Cory: Bye everyone.
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!