Recorded with Cory four months into new motherhood (and Michelle pushing through COVID), this one is personal: nothing teaches you what predictability does for a nervous system like losing it. From a newborn with no circadian rhythm to the kids who swear at you if you change your glasses, the conversation makes the case that rhythm, routine and predictability are not common sense, they are foundational, and they are the base everything flexible is built on.
Cory had a baby since the last episode, and four months in she is living the topic: the sheer disorientation of losing predictability, a newborn who does not arrive with a circadian rhythm, and the discovery that a simple bedtime routine, bath, feed, massage, book, bed, regulated her before it regulated her daughter. The three of them use that to open up rhythm, routine and predictability as a clinical cornerstone, the thing OTs know inherently and then forget, in their lives and in their treatment planning, until it is disrupted and suddenly obvious.
Tracy grounds it in the nervous system: the body builds every function off rhythm, the craniosacral pulse, breath, circadian, diurnal and ultradian cycles, and the vestibular system catches and entrains those rhythms, with auditory and even light playing their part. Out of sync, the polyvagal system can override everything and pull you toward protection. They get practical about how to read when a child loses rhythm, in speech, in interaction, on the trampoline, and how to reinsert predictability, the same entry every time, the same words, even level blinds and a tidy clinic so the therapist is free to be present. The through-line is a lovely paradox: you give rhythm in order to allow arrhythm, because flexibility, humour and high-level connection are built on a base of predictability. And it is a kind, jargon-free way to talk to families, no one’s rhythm is wrong, you are just helping everyone sync up.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Michelle: Hello everybody, hi Trace and Cory. How are you for episode 15?
Cory: Woohoo, episode 15. We are halfway to 30, guys. We will make it to 30. And I am 30 this year, so we will make it.
Tracy: And I am going to be 60 this year, so double it.
Cory: Michelle, wait, we have to mention this. Michelle has COVID, and she is still recording today’s episode. That is how dedicated she is to all the Spirited Conversations listeners out there.
Michelle: I am kind of over the worst of it, and because Cory has moved, we had to record separately anyway, so it has been fortuitous. I am a few days past the worst of it, and I love you guys, so I could not say no. Our schedules are full on, so we grab time when we can. Sorry if I am a little nasally today. It has been interesting that in our personal and work lives, this issue of rhythms and routines, performance, wellbeing and regulation is coming up for us professionally as well as personally, because we have all got ourselves a bit chock-a-block at the moment. So that is the topic of our conversation today. Cory has a particular interest. What is the thing that has butted into your rhythm and routine, Cory?
Cory: Baby. She has arrived. I did not have a baby at the end of the last episode, and now I do, and she is already four and a half months old. I think I was two months in when I messaged you both and said, can we please talk about rhythm and routine, because I am going a bit crazy with a newborn. Not crazy, but it is so much change, and I could not believe how much it affected me as an adult not having predictability. It is, okay, how do I get calm so I can calm down my baby? It obviously relates to treatment too, but the difference of two months to four months is pretty amazing, how much more you can predict and start to figure out. Those first two months were a very interesting time, just trying to find some semblance of normal. So I am very keen to chat about rhythm and predictability, and we will pull in relationship, because that has a big impact, and regulation for the child, the adult, for everybody. What do you think, Tracy?
Tracy: It makes me think of two things. First, whenever there is a disruption to your routines and predictability, you never really realise, until it is disrupted, how much it creates the background beat around how we all live and find wholeness and wellness, because we have that stability that comes from predictability. So when it is challenged, it becomes ever so evident, right in front of you. I also want to tie it to the STEPPSI tool, because when we were developing it, we analysed our treatment sessions, and there was this undercurrent of predictability none of us were naming for quite a while. Then we watched each other’s sessions one after another, and what we realised, especially for more senior clinicians, was this super intentional way of starting and stopping sessions, a really obvious emphasis on predictability that none of us were naming. It jumped out at us, the way you do shoes is the same every time with that child, and different with this child, but clearly intentional, and how you come and go with the parent. Suddenly it was, wait, predictability. Once we named that element, it took on a bigger life than any of us knew. In our tradition as occupational therapists, the notion of predictability and routines is really inherent to our practice, but we forget about it, in our lives until the baby is born, and in our treatment planning until it becomes a cornerstone. So that is the frame: what is this, how does it function in our lives, why is it so important, and how do we harness it for the significant role it plays in overall adaptive capacity. In the COVID era, every day we have more families and children in crisis, and the answer is often in relationship and predictability before we go to anything else, so it is important that we find some mindfulness about it.
Michelle: There is a shared sense, between us and listeners and across the world, that there is a lot going on to disrupt even our values and principles. I am wondering about the neuroscience, about evolution and survival. It feels like the purpose of rhythms and routine aids regulation, perhaps around us being in some kind of internal synchrony, or energy use. Do we want rhythms internally so we have got some energy to expand when things are disrupted or we need to survive?
Tracy: It totally makes sense. The nervous system establishes every single function off rhythm. There is a rhythm of the craniosacral pulse, of your breath, of the in-and-out exchange at every level. All those rhythms, cellular and exchange, have to find calibration, and mis-signalling tips the nervous system out of safety into activation or deactivation. That is a reflection of polyvagal theory: if we are not in a state of safety, the nervous system has to mobilise resources to survive, and there is a really primitive quality to that. So if your internal rhythms are out of sync, if you get out of sleep synchrony, which is what happens with a baby, Cory, it is a window into how primitive having established circadian, diurnal and ultradian rhythms is. When those rhythms get out of sync, all the rhythms are out of sync, and that out-of-sync state does not let you establish your foundation of where you are operating from. In day-to-day life, rhythm is important to our wellness, and when people are out of sync and do not have rhythm or predictability, you feel it in the vibe, in the tension patterns of interactions, and you see people going to really intense, primitive ways of interacting and controlling. Your sense of control can be released when you are in safety; when you do not have control or safety, you get really intense, unusual behaviours.
Cory: Neurologically, when we receive rhythm to the nervous system, are we just wired to want rhythm? Can you walk us through how rhythm impacts our nervous system, or is that too complicated for a simple discussion?
Tracy: On some basic levels I can, without going too far into the weeds. Rhythm is partly established through the vestibular apparatus. The vestibular system helps to catch and entrain rhythms and set the tone for them, and some of the sleep and wake cycles partly emanate from there, they can entrain to the system because of vestibular function. The vestibular-auditory connection that establishes entrainment is important to acknowledge too, it is a partnership. Even in utero, light also plays a really important role in establishing sleep and wake cycles, the level of light and dark exposure, through particular receptors that are actually in the periphery of the body, so it is not just the visual system. It is also based on activity, we have waxing and waning levels of intensity through the day, and the baby was used to that in utero, movement for these hours, quieting for these hours, and movement itself is vestibularly mediated. The nervous system is also supported by a fluid system moving in rhythm, surrounding the spinal column, so you can establish rhythmicity in the craniosacral system, then in the respiratory and cardiac systems. All those basic physiological systems derive information from rhythm, but they are also fuelled back from the basic regulatory functions of the polyvagal system. So if that system signals you should be heightened, it overrides anything else, you cannot get into a normal sleep-wake cycle if it is signalling, no, you cannot rest, you need to protect yourself. These systems are not fully hierarchical or linear in how they fire, they work together as a whole gestalt, which is why sleep is so complex, it is not one thing that disrupts it, it is any and all of this. And when people have unusual prosody, an unusual way of interacting that is not in rhythm, sometimes the issue is not in their language or social system, it can go all the way down to a basic level of regulation or even vestibular function.
Michelle: Is there a universality in humans to seek out or respond to rhythm in the same way? Working with kids who are not neurotypical, whether ASD or ADHD or environmental trauma, sometimes it feels harder for those bodies to sync up in a rhythm or hold onto one, and I just trust there is an impact of rhythm we should keep going for. Is it universal, this concept of rhythm being adaptive, even though some profiles resist it or find it harder to sink into?
Tracy: Absolutely. Universally, all beings have this organisation that happens off rhythm. You can look at rhythm studies down to single-cell organisms and all the way through the most complex organisms, which may not be humans given how we are operating on the planet right now. At every level, what is interesting is that the nervous system, even of a very primitive organism, is basically a match-mismatch machine. People into coding love that about the nervous system: does it match, does it mismatch? Match-mismatch is rhythm-seeking, it is looking for the pattern. If the pattern makes sense because it matches and entrains easily, that is great; if it entrains in a more complex way, that adds challenge. So when you are with a child who is not processing easily, one of the things we do is super intentionally bring our interaction to more predictable rhythmicity, the way we move, breathe, talk and parse our language all become far more predictable. If you and I just talk without thinking about rhythm, we talk off rhythm, normal adult speech is arrhythmic, and we can weather that, in fact it keeps each other’s attention, it keeps us affectively connected, the unpredictability is what is interesting and fun. But when we start to lose each other, we pause and bring the rhythm back down and reconnect around the rhythm of the exchange, remembering it is about reciprocity. When you leave a social interaction where the ratio got really out of sync, you notice it, that person did not allow me into the conversation. So it is all about rhythm and predictability, and then the lack of rhythm and predictability that brings the interesting quality. For someone struggling to process information, finding a way to insert predictability and keep it steady, but keep it novel and interesting enough, is equally important. With a couple of kiddos I have treated, I can tell I am losing them if they start to get too rhythmic and pedantic in their speech, versus if I scaffold them a little and allow more freedom, and then it comes back.
Cory: What do you mean you start to lose them if they get too rhythmic? Do you mean they are trying to maintain their regulation when they become really rigid?
Tracy: You might see more specific, precise language use with an overemphasis on rhythm, or the opposite depending on the individual, more perseveration, getting a little stuck on an anchor point, I need that anchor point to help me move through this processing and conversation. You notice it, and what you notice in yourself is a pull to compassion, frustration or curiosity, whatever it is, but it is affective, it has a tone that triggers, hmm, we are not quite in sync right now.
Cory: So in a session I will be playing something and suddenly, oh, we are not on the same page, that feeling where the child has gone back to their familiar or is really stuck on something. Is that what you mean by rhythm in the interaction? Because there is rhythm in so many things.
Tracy: That would be rhythm in the interaction, or it could be rhythm in the interaction and in the action pattern itself, not just the speech pattern. Maybe I am with a child jumping on the trampoline and I see them lose their rhythm and they cannot maintain the bilateral vertical acceleration. You could think, maybe they lost their postural control or stability, but did that happen because they lost their rhythm, and did the rhythm signal get lost because of something? It very often tags back to rhythmicity, and how you re-establish it is through offering predictability cues, here is how I re-establish my jump. So predictability and rhythm are cornerstones to observing what is happening for the individual and offering the right scaffolding as a path forward.
Cory: So for kiddos who get a little sticky, sometimes you catch it in the moment and you increase predictability, or offer something familiar, which is predictability, and that lets them become adaptive and shift forward. Sometimes you do not catch it and you just have a really hard session, and you come out going, that was terrible, even though there were probably plenty of good moments. So I am thinking about ways to increase predictability when you are coming across sessions like that. These concepts are supposed to be common sense, but you forget, you think, how could I change the activity, instead of increasing predictability for some of those sticky kids, in relationship and in the whole gestalt of the session, the start, the middle, the end. One example for me: there is a child for whom, if I change up too much, even changing my glasses, it is really upsetting and she will swear at me, she will let me know, the F-words start flying as soon as she comes in if there is one thing a little upsetting. That is so clearly a teachable moment, so for that child I do the same entry every time, stand in the same place, the same language, the same thing every time, and just having that has allowed things like glasses changes to be okay, because there is predictability in other places. Michelle, have you thought about ways you have done that?
Michelle: I think about it in terms of the child’s individual capacity for predictability. Some of the kids I work with who are higher functioning do not need that level of help, you do not even really think about it, they can take their shoes off anywhere versus a specific spot. So I am paying attention when they come in, because for some you need to layer on predictability in our tone, the glasses, where we sit, how we start, even how we refer to particular pieces of equipment, because some kids make up their own names for equipment and want you to keep using that name, which is tricky to remember across a lot of kids. So some require you to pay attention to all the elements, the sensory component, our look, speech patterns, body position, whether I get on the equipment first and demonstrate it or they get on first. Sometimes I micromanage every component, all the elements we go through with the STEPPSI. Other times I alter some components, so we come in the same, I enter the same, the same language, but the challenge is, I want to help you be more flexible and manage the unpredictable, because life is unpredictable. So I need to help you regulate through things that do not line up. But the first step is to line up predictability to ensure trust, safety and regulation, and then add the challenge. It is clinical reasoning to work out which thing they manage when you change it, maybe Cory’s glasses, maybe the name of the equipment that I forget each week as a little challenge. Sometimes they just need us to be predictable, and all the rest, the equipment, the room, the glasses, the hair colour, can be fluid for them, as long as I, or the carer, am predictable.
Cory: There is also environmental predictability in the clinic itself. Even we as therapists, when the clinic is a mess, you come into that treatment space and it already elevates you slightly, because you need to be able to find the thing you want when you need it, the brush, without having to disconnect from the child. We have had many evolutions in our clinic around putting up visuals for us as therapists, guys, put it back in the right spot, and I am not even like that in my real life, but in the treatment space I need it in the same place and not cluttered, so I can take that off my load and be present, the same way the child needs her glasses to be the same.
Michelle: Sometimes that is just our preparation, claiming the space. I level the blinds, we have a dark one and a light one, and I have to have them even. There is nothing useful or practical about it, it is just, as I am in the room thinking about the client, I level the windows so everybody knows the blinds are even.
Cory: That is your routine, setting up for a session. If you did not have it, you would feel a level of unsafety. You are not OCD, you do not need the blinds exactly even, but having the routine in place sets you up to be ready for the child or family. I need the environmental piece set up so I can take it off my load and be present.
Tracy: And your client needs her glasses to be the same so it can free her up to be present in whatever challenge is coming along.
Cory: Right. On your Spirit model, Tracy, it is that whole attain versus maintain versus challenge. Are you attaining regulation, maintaining it, or challenging it? It is a continuum you move back and forward on. If I have a child where I have not even attained regulation, this is where rhythm, regulation and routine come in so strongly, because I can attain it so much more easily, which means they can move to challenging it without me having to do too much. Because life is hard, there is so much we cannot control, that if I can get to a place where I have attained it robustly, they naturally want it. We are always dancing around that edge of how much to push and how much to support, because for some kids it is just slower, they need so much more predictability, rhythm and routine, and can still only attain it for a short time. Michelle, you said some profiles have a resistance or it is harder. I wonder if it is less a resistance and more that it requires more nuance from us to find their rhythm.
Michelle: I was thinking about profiles. Some kids who are more activated and on the go, the predictability has to be faster and more fluid, and sometimes there needs to be novelty to it. Versus kids who have not got a strong sense of safety and a wide window of tolerance, predictability is going to look a lot slower, steadier, more purposeful and nuanced than for an on-the-go profile. The need is still the same, but it looks so different. I am working with some cherubs now at a really low developmental capacity, getting moments of regulation and stillness, with a more defensive withdrawal profile, so that is really gentle work and I give lots of thought to every layer I can make predictable and rhythmical, versus kids with a more approach, mobilised profile, where I am still trying to get rhythm in, but it feels different, I am trying to slow them down and sync with them.
Cory: I totally know what you mean, because, like Tracy said, the novelty of conversation can catch us, it is arrhythmical. I was thinking about monotonous university lecturers, no matter how interested you are, you end up falling asleep, because it is so rhythmical you cannot stay with it. So for those kids who need a bit more, you are not going to make it so purposely rhythmical that you lose them and they feel this is boring, I need novelty.
Tracy: So true. We have to attune to their rhythm that regulates them and their rhythm that keeps them engaged, always working at those levels, regulation to support engagement, regulation to support engagement. In the Spirit model we talk about the low route and high routes of the sensory, affective and motor functions, but I am aware that predictability and rhythm also have a low route and a high route. Flexibility derives from predictability. Predictability is in the lowest routes, in the basic vestibular processing, in both discrimination and modulation flavours. Flexibility is a high-level skill that derives out of all the rest. So we give predictability for the purpose of this high-level arrhythm, we give rhythm to allow arrhythm. High-level social interaction, complex problem-solving and language interaction all happen arrhythmically, but you cannot get there if you do not know the base of predictability underneath it. So we attune to the rhythm, then to the arrhythm, and help kids and parents find synchrony, so that when I do something rhythmic to ground you and then something arrhythmic to help you find laughter, I do not get out of sync myself because I so crave the arrhythm that I forget the rhythm. Often we are coaching parents or educators around a basic rhythmicity, then embedding that in relationships, routines and the predictabilities of the day.
Cory: We are helping ourselves, parents and educators see the value in rhythm, predictability and routine, across the whole day or in a moment. With a newborn, when it is chaos and you are sleep-deprived, it is tricky to tackle it all at once, so people can think about particular times where it is more readily available to implement a routine. It can be hard to go, okay, I am going to do a whole sensory diet, I love sensory diets, but the load can be hard unless you are already in a good place. In sessions, the big key parts I think about are the start and the end. If a child is having hard transitions out, I am always thinking, how do I increase the predictability around the fact that we are transitioning?
Michelle: Which is almost why you chose to do a nighttime routine. I start to think about what is most critical for this little family, and mostly it is sleep, and relationally it is repair. At night I often start with the nighttime routine, because it sets everybody up for good sleep hygiene, and everything starts with a good night. Then, particularly for busy families with kids in school and both carers working, it is the morning I want to do with the most flow and least resistance, all the clothes laid out, but also relationally, so kids are not landing at the most demanding place, school, with the minimum of energy and conflict, ready to do the work that is important. Same in the clinic: we set up the start and the finish, the bookends, so we can do the work in the middle. Sometimes that is environmental, sometimes relational, a meet and greet in the waiting room with the ones tucking in under mum’s wing, adding predictability to the handover. In sessions I focus on a predictable start and stop, but also multiple times throughout, how do I start and stop an activity, start and stop the relationship, and if things go awry, how do I repair that, from a task point of view and relationally. I layer the sensory component on after those firm foundations are bedded down and everybody has a little energy to think about something else.
Tracy: There is also a quality of prioritising predictability and routine, but then pretty naturally you add rhythm, so these three bits go together. Even thinking about the starting and stopping, you are probably enhancing rhythm a little, using a more anticipatory cue with your voice, a one, two, three, ready, set, it is coming to a beginning, it is coming to an end. That anticipatory cueing, preparing the system for a shift, is all part of rhythm, and our routines come from rhythmicity. If we are mindful about layering those pieces, kids start to make sense of what is happening, just like Audrey makes sense of, oh, it is bedtime now, Mum, it is time for nursing, time for a nappy change, time for that back-and-forth laughing we do. It all comes from rhythmic cueing, and those turn into predictable patterns that become routines, which we can use as a scaffold for all kinds of things, not just for a four-month-old but a 40-year-old who has a new job at a new pizza parlour. It translates across the whole lifespan.
Cory: Michelle, you mentioned adding sensation after establishing the firm foundations with parents. When working with parents or educators, you start with the firm foundations, the rhythms over the day and good routines, and then once those are in place you add the layers around sensation, maybe a sensory diet. Is that what you meant?
Michelle: Yeah. For some kiddos the foundation is sensation that helps with regulation, predictability and relational development. But other times I meet families where the whole unit just feels a bit chaotic, and it feels like firm hugs or deep breaths would be another thing that does not land on a solid base. So that is what I am thinking about when I coach families about rhythm and routines at home. In the clinic, relationally and from a movement and sensation perspective, sensory input is foundational, even how I say hello and approach a child, the movement I use, the prosody of my voice, how loud or soft, whether I even talk. It is so integral that we are always thinking, what sensory-motor input am I providing this child, and is it supportive for them or not? You beautifully weave sensory-motor input into your interventions, Cory, I have seen you with your nursery rhymes. How do you think of sensation in intervention?
Cory: Similar to you. You have your bookends, and if those are established you can dive into the weeds of your session. Each moment, are you offering something familiar and predictable, or novelty? That is in the activity, the interaction, the same song or a new one, the movement and the way you play. If a kiddo is really dysregulated for whatever reason, maybe the toy they wanted was not in the room and that is the end of their ability to stay regulated, that is nothing you have done, but you have to support them back to a place where you can move forward. Sometimes that is in the Lycra, no talking, lights off, just swing you, no language, no load, just get you back. For other kids, all you have to do is go, oh, and you have pulled them back in. It depends on the activity, the relationship, and how much prosody, how quickly I speak, how intense or soft I make my affective cueing. In every one of those, it is always about whether it is more rhythmical and predictable, or whether you are adding novelty.
Tracy: Absolutely. And it is why the more arrhythmic and out of sorts the session, the child or the family is, the more we need a tool like the STEPPSI, where I can tick through, what are my opportunities in sensation, task structure, environment, predictability, and in the way I use my interactional style and ability to co-regulate, and how is that related to the attain, maintain, challenge dimension. Learning to use that tool really helps, especially in those moments where it is imploding and you do not know what to do, or, I really feel you are suffering here, family, and I would love to layer in some supports. We have to start from that base of predictability to build toward the arrhythm, and if we are in chaos, we have to get to predictability to even have a starting spot.
Michelle: It provides a lovely, normalising way to talk to a family. That is how we started today, we are all a bit taxed at the moment, because it can just be about a mismatch. I see families where there is a mismatch in their rhythms, and no one rhythm is more right than the other, they are just not matching yet. So it lets you say, you have got this rhythm, the little kiddo has got this rhythm, let’s help you sync up and find rhythm together, so everybody’s needs are met and no one is wrong or right. It is a human need, we have all got a rhythm that feels right for us, and if we are going to relate together, we need to sync up. A really positive, no-blame, matter-of-fact way to talk about it.
Cory: And really understandable, not jargon, not a lot of neuroscience to explain. Everybody has an internal experience of being out of rhythm and out of routine, so it is easy to draw on for anyone.
Tracy: So true. In a funny way, amid all the tension of the world these days, I notice it in driving, people are out of rhythm, and I have made this commitment to be as predictable and clear as I can on the road, as a way to say, if I can find some rhythm and offer that to the world, maybe that will help. Rhythm and predictability are the way we are all going to find our way forward, and we can offer that to each other. We should all sway to a little music and be together in a little bit of rhythm, and find some synchrony.
Cory: Maybe I will do the same when I am driving, Tracy, that seems like a nice way to be in the car. All right, you two, we will talk to you next time.
Tracy: Thanks everybody, 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!